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Definition “Inability of a man to maintain an erection sufficient for satisfying sexual activity” http://oxforddictionaries.com/definition/english/erectile-dysfunction History 2500 BC: Ancient Chinese philosophers believed that a man’s yin and yang were out of balance by age 60, and without enough life-giving yin, he was bound to run dry on sexual energy. They used potions to treat as they still do today 1600 BC: The Egyptians believed that impotence was the result of a natural disorder or an evil spell. They had many remedies to ward of the ED curse — including grinding up baby crocodile hearts to rub on the penis. 1000 BC: The Mayans also used Lotus Flowers as the Egyptians. History 300 BC: Aphrodisiacs and the Goddess of Love - The word "aphrodisiac" comes from Aphrodite, the Greek goddess of love. In about 300 BC, Aristotle, the Greek philosopher, extracted an aphrodisiac from the dried bodies of beetles also known as Spanish flies. We now know it is too toxic and ineffective to treat ED. The Dark Ages: Blame It on the Devil? - In the 13th century, the medieval theologian Thomas Aquinas believed that demons were the most likely cause. Men with impotence problems were urged to track down the women who had bewitched their penises and persuade them, with violence if necessary, to restore their erections. History 1600-1900: From a Woman's Hand to the Hands of Science During the 1600s, the general view on erectile dysfunction was that if a woman's touch couldn’t cure a flaccid penis, nothing else would. However, by the end of the century, scientists had discovered that it was actually the bloodsupplying arteries that lead to an erection. Researchers got to work, and by 1873 the first surgical treatment for erectile dysfunction had arrived. An Italian doctor successfully treated ED by blocking veins that drained blood away from a penile erection. History Early 20th Century: Weird Science – In 1918, a Russian doctor came up with the idea of transplanting monkey testicle tissue into humans (seriously!!!!). 1960s: The Rise of the Penile Implant - The earliest penile implants were based on the observation that many animals had actual penile bones. But attempts to implant bone or cartilage into the human penis failed because the grafts were quickly absorbed. History 1970s: Penises Get Pumped Up - In the 1970s, a Pentecostal minister with a tye repair business on the side figured out how to attach a tire pump to a cylinder, create negative pressure, place the cylinder over his penis, and pump up an erection. 1980s: Introducing Penis Injections - This medical advance occurred accidentally. A French surgeon unintentionally injected the drug papaverine, used to open up blood vessels, into someone’s penis, and it caused an instant erection, the beginnings of intra-cavernosal injection ED therapy. “Blue Pill” 1990s - Present: The Little Blue Pill Is Born - In 1994, another accident occurred. Researchers found that sildenafil, a drug being studied to treat angina, also caused erections. In 1998, the FDA approved Viagra to treat impotence, and it was soon followed by Cialis and Levitra. And just five years after oral ED drugs appeared, erectile dysfunction diagnoses had increased by 250 percent. Risk Factors Lack of exercise Obesity Smoking Hypercholesterolaemia Hypertension Metabolic syndrome Diabetes mellitus Drugs Antihypertensives Beta-blockers Diuretics Antidepressants: both tricyclics and selective serotonin reuptake inhibitors (SSRIs) Antipsychotics: phenothiazines, risperidone Hormonal agents: cyproterone acetate, luteinising hormone-releasing hormone analogues Anticonvulsants: phenytoin, carbamazepine Antihistamines Recreational drugs H2 antagonists cimetidine and ranitidine The Big Question??? It’s about your confidence, not only in asking the question but taking a thorough history and how you approach this. Taking a History How long has this been going on? Was it sudden or gradual onset? Are you getting early morning erections? Do you get good quality erections when you masturbate? If you get an erection does it disappear when you go on to make love? Do you have an understanding partner? BLOODS??? Older men ? Prostate EXAM but not really related to ED Biochemistry of Erection Pathophysiology of Erection Prescribing Policy-ED • • • • • • The prescribing of drugs for ED on FP10 was formerly covered by Schedule 11 and has since been enshrined in Part 3 para. 42(2) of the National Health Service (GMS Contracts) Regulations 2004. This laid down clear criteria for prescribing, in that treatment on the NHS should only be made in men who: – Have diabetes, multiple sclerosis, Parkinson’s disease, poliomyelitis, prostate cancer, severe pelvic injury, single gene neurological disease, spina bifida or spinal cord injury. – Are receiving dialysis for renal failure. – Have had radical pelvic surgery, prostatectomy or kidney transplant. – Were receiving Caverject, Erecnos, MUSE, Viagra or viridal for ED, at the expense of the NHS, on 14 September 1998. – Are suffering severe distress as a result of impotence – prescribed in specialist centres on FP10HP and NOT by GPs on FP10 The policy of Mid Essex Clinical Commissioning Group (CCG) is that NOT more than FOUR doses per month should be prescribed. Pumps for erectile dysfunction can be prescribed on FP10 and should be endorsed ‘SLS’, they can only be prescribed for patients falling into the first three categories listed above. GPs should NOT prescribe PDE-5 inhibitors for penile rehabilitation since this does not meet ‘SLS’ criteria for prescribing on FP10s and should refer all patients back to the consultant recommending treatment for ongoing management. Guidance on the CCG website-http://www.midessexccg.nhs.uk/Your%20NHS/obstetricsgynaecology-and-urinary-tract-disorders.htm 12 month ED expenditure MECCG BNF Name Mediwatch UK ErectEase Vacuum Pump Osbon ErecAid Classic Vacuum Pump Osbon ErecAid Esteem Vacuum Pump iMEDicare Select Maint Set Constrictor Ring iMEDicare SomaCorrect Vacuum Pump iMEDicare SomaCorrect Xtra Vacuum Pump iMEDicare SomaErect Response II Vacuum Pump iMEDicare SomaErect Response II XL Vacuum Pump iMEDicare Ultimate (Surefit) Maint Set Constrictor Ring iMEDicare Ultra Maint Set Constrictor Ring Total Items Total Act Cost 1 £86.64 1 £96.41 1 £171.22 1 £26.78 1 £146.63 7 £1,156.34 17 £2,523.51 4 £593.44 22 £816.22 4 £156.93 59 £5,774.12 Which ED drug? BNF Name Alprostadil Sildenafil (Erectile Dysfunction) Tadalafil Vardenafil Total ItemsTotal Act Cost 488 £23,421.14 9,115 £247,789.07 5,642 £194,520.20 905 £23,629.20 16,150 £489,359.61 Tadalafil (Cialis) has been recently licensed for benign prostatic hypertrophy but remains non-formulary for all indications and therefore should not be prescribed. Technology Appraisal Guidance No. 273 January 2013 NICE is unable to recommend the use in the NHS of tadalafil for the treatment of symptoms associated with benign prostatic hyperplasia because no evidence submission was received from the manufacturer of the technology. Annual cost of ED drugs Annual cost of Sildenafil 100mg 4 per month is now £18.00 (Oct 2013) Erectile Dysfunction-Prescribing Guidance • • • Prescribe generic Sildenafil first line since Viagra® is now off patent-June 2013. Avoid branded prescribing. Savings on sildenafil £20,000 per month from Oct 13 as now Cat M. Prescribing of Tadalafil (including daily Cialis®) and Vardenafil (Levitra®) is nonformulary and not supported. Ensure that all patients prescribed on the NHS meet ‘SLS’ requirements and are not prescribed more than 4 tablets per month. For Prescribing Incentive Scheme Upper threshold for generic sildenafil is 75%. Treatments PDE5 blockers Pumps Caverject Psycho-sexual counselling +/- relationship counselling – including sensate focus A word or 2 re MUSE Implants Last resort as once erectile tissue removed if complications no going back. Bendy implants and pumps. Main complications are infections and erosion Not available on the NHS Conclusion Extra: The PSA Debate & any other questions?
