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Erectile Dysfunction
And it’s Multiple Treatment Options
Priapus son of Zeus and Aphrodite

Cursed by Hera with
eternal impotence,
ugliness and foul
mindedness. Due to
hero, Paris judging
Aphrodite to be more
beautiful than Hera.

Erectile Dysfunction (the inability of a
man to achieve or maintain an erection
sufficient for his sexual needs and the
needs of his partner)

Erectile Dysfunction can mean inability to
achieve erection, inconsistent ability of
having an erection, or ability to achieve
only brief encounters.


1. Incidence of ED
a. National Institutes of Health,
estimates 30 million men in US have
ED.
 b. Transient ED and inadequate
erections occur in 50% of males
between the ages of 40 and 70y/o.


c. Psychological factors account for 10
to 20% of cases of ED.
d. 35 to 50 % of men with diabetes
have ED.
 e.
68% of men with hypertension
have some degree of ED.
 f. Highly related to age.
 g. ED maybe the first sign of CVD.
 h. Smoking increases rate of ED at
all ages.

Harvard School of Public Health
◦
◦
◦
◦
Study of 31,742 men between the ages of
53 and 90. Mailed questionnaire in 2000.
(Published in Annals of Internal Medicine, Aug5
2003.)
At age 40 to 50-----4% ED
At age 50 to 59 ---26% ED
At age 60 to 69----40% ED
At age >70 --------61%ED
Estimated Prevalence of ED in U.S.
Prevalence and count (in millions) of US men aged 20 years and older by
category of erectile function.
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The American Journal of Medicine
Volume 120, Issue 2 , Pages 151-157, February 2007
Causes of Erectile Dysfunction

Vascular
◦
◦
◦
◦
◦

Diabetes
Hypertension
Cardiac Dz
Dyslipemia
Smoking
Neurogenic
◦ Stroke and or trauma

Psychogenic
◦ Stress and/or Anxiety
◦ Depression

Hormonal
◦
◦
◦
◦

Hypogonadism
Hyperprolactinemia
Chronic Disease
Thyroid Disease
Physical
◦ Renal Failure
◦ Liver Failure
◦ Alcoholics and/or Drug Addicts
Medications associated with ED







Antihypertensive medications
Antidepressants
Tricyclic antidepressants
Antipsychotic agents
Antihistamines
CNS depressant narcotics
Sympatholytics
Physiology of Erection

Penile erection elicited by central
psychogenic and reflexogenic mechanism.
◦ Psychogenic erections are elicited by auditory,
visual, olfactory, or imaginary stimuli.
◦ Reflexogenic erections are elicited by
stimulation of sensory receptors on the penis,
which through spinal interactions cause
somatic and parasympathetic efferent actions.

With arousal, parasympathetic activity
triggers release of nitric oxide.
◦ The increased nitric oxide causes increased levels of
intracellular mediator cyclic guanosine
◦ monophosphate (cGMP)
◦ Increase in cGMP causes penile vascular and
trabecular smooth muscle relaxation. Blood
flow then increases into the corpora cavernosa.
 The rapid filling of the cavernosal spaces compresses
venules and causes a decrease in venous outflow. This
causes increased inflow and decrease in outflow
causing the erection. (Veno-occlusive mechanism)
Testosterone

Hypothalamus –GnRH
Fsh + LH


Testicles
 Testosterone Production

Aromatase enzyme in fat
 Estradiol
Testosterone Effects





Increased Libido
Enhances Mood
Increases Energy
Increases Bone Density
Decreases body fat and increases lean
muscle mass.
◦ Men with low T are 2x as insulin resistant as
men with normal T. ( Pitteloud et al 2005 )

Responsible for secondary sex
characteristic.
Testosterone improves neuron
survival in brain regions
vulnerable to
neurodegenerative disease.

Cognition and alertness
Low Testosterone Effects







Poor Libido and ED
Lower blood Hb and loss of body hair
Decrease muscle mass and Fatigue
Osteoporosis
Depression
Decrease in cognitive function
Decrease sperm production
Ranges of normal
testosterone levels

PRL Lab
◦ Total Testosterone 240-950ng/dl
◦ Free Testosterone 9-30ng/dl

Quest Labs
◦ Total Testosterone 241-827ng/dl
◦ Free Testosterone 46-224 pg/ml

Lab Corp
◦ Total Testosterone 348-1197ng/dl
◦ Free Testosterone 6.6-25.1 pg/ml
Normal Testosterone Levels in Men (Non-Diabetic)
Measurements in Conventional Units (ng/dl)
Age
Number
of
Subjects
Mean
Total
Test
<25
125
158
697
408
468
956
25-29
354
692
669
206
637
388
438
1005
30-34
330
621
194
597
348
388
975
35-39
212
189
567
329
388
945
40-44
148
198
597
319
378
936
45-49
154
163
527
329
358
846
50-54
164
187
518
289
348
936
55-59
155
597
597
546
544
552
174
547
319
338
866
Stand.
Dev.
Median
Total
Test
5th %
10th %
95th %
Vermeulen, A. (1996). Declining Androgens with Age: An Overview. In Vermeulen, A. &
Oddens, & B. J. (Eds.), Androgens and the Aging Male (pp. 3-14). New York: Parthenon
Publishing.
Testosterone side
effects:
 Sleep
apnea
 Polycythemia
 Liver toxicity
 Prostate disease
 Shrinkage of testes
Estradiol levels in Men

Estradiol levels greater than 34.1 pg/ml
are associated with:
◦ 2.2 greater risk of stroke (Abbott RD, et al,
Neurology, 2007, Feb 20) These were 2,197
men aged 71 to 93 yrs.
◦ Men have excess estrogen due to decreasing
testosterone and increased weight with aging.
Aromatase enyme is increasing the amount of
estrogen present.



High Estrogen in men with Coronary
Atherosclerosis
Carotid artery intima-media thickens with
high estrogen.
Low testosterone and high E-2 is
associated with lower extremity peripheral
artery dz in elderly men.
Aromatase Blocking Agents

Non-steroidal aromatase inhibitors (AIs)
anastrozole (Arimidex®) and letrozole
(Femara®)
◦ Anastrozole .5 to 1mg weekly and check
estradiol levels . Keep estradiol above 20 and
below 35 pg/dl.
◦ Letrozole 2.5mg weekly and off when estradiol
level below 35 pg/dl.
PDE-5 inhibitor, this increases cGMP
causing smooth muscle relaxation

Sildenafil Citrate (Viagra) lasts 4 hrs.
◦ 25,50,100mg take 1hr prior to sex


Tadalafil (Cialis) takes effect in 15 mins
and last 36 hours. Greasy food doesn’t
effect this. (2.5,5,10,20mg)
Vardenafil (Levitra) given 1hr prior to
sexual activity and last 5 hrs.
◦ 2.5, 5,10, and 20mg.
First line drugs for ED
Male Sexual Response
(4 phases)
 Desire
 Arousal
 Orgasm
 Relaxation
PDE-5 inhibitor Side Effects
 Headaches
 Facial
flushing
 Indigestion
 Nasal Congestion
Failures of oral and
intraurethral medications are
txed with:
 Vacuum
pump
 TriMix
 QuadMix
Vacuum Constrictive Devices




Has been utilized for the last 100 years
Has gained popularity in last 20 years
Is FDA approved for ED
Negative pressure of 200 to 250 mmHg
◦ This neg. pressure increases inflow of blood
◦ into the corporal bodies, both in arteries and
veins.
Vacuum Constrictive
Device for ED



Effective for mild to moderate ED.
70 to 80% effective for erection.
Suction increases blood flow and a ring
goes on the penis after the erection
occurs. The ring must be removed in 20
to 30 minutes.
Vacuum Devices

Double pumping using vacuum increases
comfort for pt.
◦ Generate neg. pressure and then let some out
and wait for 2 to 3 mins, then rebuild neg
pressure until a erection occurs.


Penis tends to be purple in color and cold,
due to neg. pressure.
Decrease in force of ejaculation and
amount of ejaculate, this is due to the
constriction ring.
Premature Ejaculation


the occurrence of ejaculation prior to the
wishes of both partners.
1.Global Study of Sexual Attitudes and
Behaviors and other sources suggests
a global prevalence of PE of
approximately 30% across all age
groups.
Treatment of PE

Sexual therapy
◦ The squeeze technique





Medications
Antidepressants
Topical anesthetic creams
Desensitization of penis
Cognitive behavioral therapy
IC injection with Trimix or Quadmix
Indications for TriMix and
QuadMix
 Failure
 Failure
of oral therapy
of intraurethral
prostaglandin.(Muse)
 Failure of Vacuum Device
 Treatment of Premature
Ejaculation
TriMix

First Introduced by Bennett et.al..,1991
◦ His success rate was 92% in 116 pts.

American Urologic Association feels the
intracavernous injection is the most
effective non-surgical treatment for
erectile dysfunction
Formula of Trimix and QuadMix

Trimix
◦ Contains prostaglandin, papaverine, phentolamine.
Good refrigerated for 1 month.
 Frozen, good for 6months.
 At room temp, Trimix is good for 1 week.


QuadMix
◦ Contains small amount of prostaglandin, and
normal amount of papaverine, and phentolamine.
Also contains atropine.
 Atropine is used for the firmness. The prostaglandin
can cause groin pain for some pts.
Prostaglandin E-1(Alprostodil)


1.Prostaglandin E-1 is used to increase firmness
of the erection and to manipulate the duration as
well.
a. A potent vasodilator, causing
muscle cells of penile arteries to
relax. Blood increases in penis and
erection becomes firmer.

 b. May cause transient dull ache at
base of penis, usually resolves in 15
mins.
◦
c. Rarely causes priapism by itself.
Papaverine
(phosphodiesterase inhibitor)



Increases the duration of the erection.
Relaxes muscle cells in arterial wall.
This causes dilation and increases
blood flow in the penis.
May cause increase in liver enzymes
(rarely).
Phentolamine
(alphaadrenergic antagonist)

Blocks nerve transmission that causes
the arterial wall to contract. This causes
artery to dilate.
Helps with engorgement of the penis.
Quad-Mix also has atropine, as
well as papaverine, phenolamine,
and prostaglandin E-1.


Used to increase firmness when patient
has pain from PGE-1.
a. Not to be used in glaucoma or if pt
is on nitrates for cardiac Dz.
TriMix and QuadMix Formulations
Intracavernosal
Injection
Possible Side Effects of Trimix






Bruising at injection site
Penile pain or groin pain
Hypotension
Fibrosis
Rare increase in liver enzymes
Priapism
Complications of Intra-Corporeal
(IC) Penile Injections:




a. Hematoma at injection site. Apply
pressure to site and bleeding stops.
b. Priapism, an erection lasting 4 hours or
more. Tx –1%phenylepherine .2ml
with.2ml lidocaine given IC.
b. Pt. usually complains of severe pain in
groin and penis, if the penis is 100% plus
erect.
c. Inadvertent injection into urethra.
Contraindications for Tri-Mix


a. Severe Peyronies Dz or Cancer of the Penis.
b. Sickle Cell Dz or Fabry Dz ( glycogen storage dz )
c. Poor manual dexterity or poor vision. (Who is going
to give the injection?}
d. Unreliability, with potential for misuse and abuse.
e .Liver Dz or elevated liver enzymes, or malaria.





f. Blood coagulation disorders ( 30 gauge needle ).
g.HIV positive.
h. Gastrointestinal bleeding or ulcer dz, or IBD
i. Severe cardiac dz or on nitrates.
j. Glaucoma, if plan on using atropine.



Surgical Inflatable Penile Implants