Download ED - The Primary Care Training Centre

Ann Marie Johnson
HCA Conference
September 2015
HCA role
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Presentation-insight into ED,
They are not alone-common condition
Awareness of all the treatment options
Risk factors same as CVD –incentive/change
Communication with partner is key
We all need to be able to hold someone close, to
be able to touch their hands, feel warm and
comforted.
• Opportunity to open the conversation and today
will start your journey to learn more about ED to
support your patients holistically.
Plan for today!
• What is it?
• Why is Erectile Dysfunction important?
• Why should we look for Erectile
Dysfunction?
• How can we find the ones at risk?
• What can we do about it?
• How big is the problem?
Definition of Erectile
Dysfunction
• ‘Erectile Dysfunction is defined as the
inability to achieve or maintain an erection
sufficient for sexual activity.’
• Impotence was traditionally applied to
erection difficulties-Latin for ‘Loss of
Power’, however, it was deemed a
derogatory term and it was exchanged for
Erectile Dysfunction.
Is sex dangerous?
• This is a concept perpetuated by the media!
(coronation street)
• Odds 1:51 million episodes of exertion, related
to sex, usually a younger partner, alcohol and
food are involved.
• Reduced risk of heart attack in people who have
regular intercourse- 2 times per week
• 1% of heart attacks are related to sexual activity
• 5-6 METS on bike or treadmill, no ECG changes
or irregular heart rate or decrease in blood
pressure-safe to resume sexual activity.
Is sexual activity beneficial?
• The Duke Longitudinal Study of Ageing
(1982)
– frequency of intercourse a significant predictor
of longevity in men
• Swedish Study (1981)
– early cessation of sex associated with
premature death
• Caerphilly Cohort Study (BMJ 1997)
– 50% reduction in cardiac death with more than
two orgasms per week
Predictors of longevity difference :
A 25 year follow up
• Past enjoyment of intercourse was a
significant & moderately strong predictor of
longevity for women. (RR 0.44)
• Calculated to equate to an extra 4.28 years
of life
• Quantity is more important for men (Duke &
Caerphilly study), but women prefer
quality !
Palmore EB. The Duke Longitudinal Study of Ageing.
The Gerontologist 1982;22:6:513
How common is erectile dysfunction
(ED)
• 52% of men aged 40-70 will have experienced
some degree of erectile dysfunction
• 39% of men aged 40will experience ED
• 67% of men aged 70 will experience ED
• 57% of men and 51% of women in ‘middle age’
report regular sex one or more times per week.
• 80% of men and 40% of women (aged 40-80
years) rate sex as an important part of their life
and half of them continue to have sex 1-6 times
per week.
Why men don’t talk about it?
• Embarrassing
• Fear-(doctor might find something
seriously wrong)
• Distress-unable to fill their partners needs
• Beliefs-if they talk about it it may get worse
• It will be fine, just leave intimacy out of the
relationship
• They don’t feel masculine if they are
unable to maintain an erection
Causes of Erectile Dysfunction
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Tobacco addiction
Neurological disease
Diabetes
Hardening of the arteries
Depression
Testosterone Deficiency Syndrome
High blood pressure
Lack of thyroid hormone
Alcoholism
Kidney/liver disease
Major causes of erectile dysfunction
Multiple Endocrine
Spinal Cord Sclerosis disorders
6%
3%
Injury
8%
Radical
Surgery
13%
Vascular Disease
30%
Diabetes Mellitus
40%
Neurological causes of ED
• Spinal cord-high complete lesionpsychogenic erections do not occur,
although many men with have reflex
erections-on genital stimulation
• Spinal cord-lower, complete, no reflex
erections
• Spinal cord-incomplete, variable erection
patterns-similar to MS.
Psychological or Physical
• Psychological
• Physical
• Sudden onset
• Specific situation
• Normal nocturnal and
Morning erections
• Relationship
problems
• Problems during
sexual development
• Gradual onset
• All circumstances
• Absent nocturnal and
early morning
erections
• Normal libido and
ejaculation
• Normal sexual
development
Relationship of T levels to symptoms
Total testosterone nmol/L
Patients (n)
74
20
69
15
Loss of libido
Loss of vigour
p < 0.001
p < 0.001
84
Obesity
p < 0.001
65
12
10
8
Feeling depressed
Disturbed sleep
Lacking concentration
Diabetes melitus type 2
p < 0.001
p < 0.001
p < 0.002
p < 0.001
Hot flushes
Erectile dysfunction
p < 0.001
p < 0.003
0
Zitzmann et al. JCEM 2006
Increasing
prevalence of
symptoms with
decreasing
androgen
concentrations
67
75
In 434 male
patients aged
over 50 years
When should testosterone concentrations be
measured?
• A low testosterone concentration is associated with increased risk of
cardiovascular events and the presence of numerous established
cardiovascular risk factors
• A low testosterone may inhibit the effectiveness of
PDE5 inhibitors
• There is currently no evidence that testosterone
replacement therapy increases cardiovascular risk
Testosterone and CVD risk factors
• TRT improves CVD risk profile
• Lowers Total cholesterol by 0.4-0.5 mmol/l (even
in men on statins)
• Significantly reduces insulin resistance
• Improves fibrinolysis
• Reduces inflammatory activation (TNF & IL)
• Improves diabetic control
• Increases Hb in CCF
Kapoor D Eur J Endocrinol 2006;154:899-906
Losing night-time erections
is detrimental to erectile
function.
Losing night-time erections
can be an early sign of
vascular disease
Shafic A BMC Urology 2007,7:14
Erection Hardness Grading Scale
• Grade 1-Penis is larger but not hard
• Grade 2-Penis is hard but not hard
enough for penetration
• Grade 3-Penis is hard enough for
penetration but not completely hard
• Grade 4- Penis is completely hard
and fully rigid
Grade 1
Grade 2
Grade 3
Grade 4
Verbal explanation of grades
• Grade 1-place your tongue inside your
cheek
• Grade 2-put your finger on the outside of
your cheek
• Grade 3-place your finger on the end of
your nose
• Grade 4-placeyour finger on your forehead
How an erection occurs
• In response to stimulation,(mental/visual/tactile)
the nervous system causes the blood vessels in
the penis to fill with blood, at the same time the
muscle within the penis relaxes allowing the flow
of blood into the corpus cavernosum, resulting in
a rigid erection.
• When the stimulation has ceased or ejaculation
has occurred, blood flow is less into the
penis,(less stimulation of the nerves), the penis
muscle then contracts which allows the blood to
flow out of the organ (flaccid penis or
detumescence occurs.
Veno-Occlusive Mechanism in Penile
Erection
Vascular
valves open
venous
efflux
flaccid
subtunical
“compartment”
arterial
Influx
Tunica
Albuginea
Vascular
valves close
Firm erection
venous
efflux
Veno-Occlusive Mechanism in Penile
Erection
venous
efflux
flaccid
subtunical
“compartment”
Tunica
Albuginea
arterial
Influx
No
firm erection
Vascular
leakage
Treatments for Erectile Dysfunction
• Oral medications-Phosphodiesterase type 5
Inhibitors- PDE5
-Viagra-Sildenfil, Levitra-Vardenafil, CialisTadalafil, Avanafil-Spedra.
• Intercavernosal injections-Prostaglandin E1
-Alprostadil-Caverject,
• Urethral application-Prostaglandin E1 – PGE1
-Alprostadil-MUSE
• Vacuum constriction device (reputable company,
not sex shop!)
• Surgery-Penile prosthesis
Compliance to medication
• 50% of men stop using the drug after the
first prescription
• 72% of men discontinue after the first year
• 70% of men have improved erections
when using the drug
• 3 out of 4 men prefer the higher dose
Getting started
• Viagra-Sildenafil 25mg, 50mg, 100mg.
Absorbed quickly, lasts approximately 4-5 hours.
Everyone is different. Increase dose if not
desired effect for both of you.
Suggest-the man takes the lowest dose, on his
own, waits an hour, places lubricant on his penis
and touches his penis for 20 mins, (magazines
or fantasy in his head may help), this way he is
in control, he can get used to the feelings and
check for any side effects, do this a couple of
times before planning a time with his partner.
The drugs are not an aphrodisiac!
Getting started
• Levitra-Vardenafil- 5mg, 10mg, 20mg.
Peach coloured
• Similar to Viagra, short acting, slower
absorption after a high fat meal, same side
effects-red face, flushing, blue haze to the
vision, and specific to Levitra, dyspepsia.
These should all subside after about 4-8
doses when the body gets used to the
drug.
Getting started
• Cialis-Tadalafil 10mg, 20mg yellow tablet
• Different to previous two, longer half life so it lasts for 2436 hours,
• Advice-make a plan-take twice a week,10mg dose, for
two weeks, the morning erections should be harder if not
increase to 20mg, masturbation solo to determine the
effect.
• Aim-find out what works for you and partner, you cannot
fail-just get wiser.
• Side effects, headache, flushing backache-all will go.
• Cialis lasts longer, more spontaneity, less planning.
Alternative therapies-if oral drugs are
not suitable
• Intercavernosal injections, erection occurs 520minutes following the injection, with or without
sexual stimulation, although subsequent sexual
stimulation will enhance the effect.
• HCP will demonstrate to patient and partner.
• High drop out rate.
• Erections may persist for 1-2 hours.
• If priaprism occurs-erection 4 hours plus-seek
medical help (A&E),
• Contraindicated-Leukaemia, sickle cell disease,
blood clotting disorders or anticoagulant therapy
Alternative therapies when oral drugs
are not suitable
• Transurethral drug application (MUSE)Medicated Urethral System for Erection (1.4mm
pellet inserted with an applicator)
• 125ug, 250ug, 500ug, 1000ug doses.
• Less invasive! a pellet is inserted into the male
urethra, following urination, 15 minutes before
intercourse is planned.
• Efficacy can be enhanced by massage and a
constriction band applied to the base of the
penis prior to administration of the pellet.
Vacuum constriction device
• Being in use since the late1800’s
• In 1917 the vacuum device was patented by Dr
Otto Lederer
• Three parts, cylinder, vacuum pump, constriction
ring.
• Caution with bleeding and clotting disordersbruising may occur.
• Use regularly, improves natural response.
• If hairy-trim, use lubricant to improve suction
• 92% success rate, regardless of cause.
• Dropout rate high due to being cumbersome
ED: BAROMETER OF MEN’S HEALTH:
The Deadly Quartet
Diabetes
Obesity
Hypertension
Dyslipidemia
36
Atherosclerosis in
Coronary Vessels
Atherosclerosis in
Penile Arteries
ED precedes CVD event by 3-5 years
Coronary calcium precedes CVD event by
3-5 years
Erbel et al
Heart 2007;93:1620-9
Diabetes and ED
• ED usually occurs 10-15 years after the onset of
diabetes (risk factors same)
• Poor diabetes control make ED more difficult to
treat (good incentive to improve?)
• 1 in 4 cases of ED/Diabetes may have emotional
problems rather than physical
• Wife’s role merges into carer/nurse?
• Downward spiral.
• Tablets for ED can help.
Take Home Message
Early Death
Early
Detectionhealth check
Endothelial
Dysfunctionrisk factors
E.D.
Education lifestyle
Erectile
Dysfunction
Is your willy working?
• If not your heart may be in trouble too
• Seek medical help – it may save your life
Final thoughts....
Just because the penis is heading in the
wrong direction it does not mean the
heart has to follow – we can, and
should, prevent it from doing so.
“The way to a man’s heart is
through his penis”