Download Consultation with the Erectile Deficient Patient - PC-REF!

Consultation with the
Erectile Deficient Patient
Jeffrey M. Spier, M.D.
Scripps Mercy Hospital &
Pomerado Hospital
Department of Urology
What constitutes an Erection ?
BRAIN CENTERS INVOLVED IN SEXUAL FUNCTION
Level
Forebrain
Region
Medial
amygdala
Stria terminalis
Pyriform cortex
Hippocampus
Right insula and inferior frontal
cortex
Left anterior cingulate cortex
Function
Controls
sexual motivation
Inhibits
sexual drive (hypersexuality when destroyed)
Involved in penile erection
Increased activity during visually evoked sexual stimulation (sexual
arousal)
Ability
Hypothalams
Brain Stem
Medial
preoptic area
Paraventricular nucleus
Nucleus
paragigantocellularis
A5 catecholamine cell group,
locus coeruleus
Midbrain
Periaqueductal
gray
to recognize a sexual partner, integration of hormonal and
sensory cues
Facilitates penile erection (via oxytocin neurons to lumbosacral spinal
autonomic and somatic efferents)
Inhibits
penile erection (via serotonin neurons to lumbosacral spinal neurons
and interneurons)
Noradrenergic innervation of anterior horn motor neurons to
perineal striated muscles
Relay
center for sexually relevant stimuli
Male Genital Anatomy
Two paired corpora cavernosa (erectile bodies) and a single corpus
spongiosum surrounding the urethra, all encased within Buck’s
fascia
The erectile tissue is comprised of a network of vascular sinusoids
surrounded by trabecular smooth muscle.
Vascular Supply
The blood supply to the penis is derived from the
pudendal artery which branches from the internal iliac
(hypogastric) artery.
Cavernosal arteries course through the center of each
corporal body and give rise to multiple helicine arteries
which open into the lacunar spaces.
Mechanism of Erection
Two types of erections – a) Reflexogenic b) Psychogenic
•
Blood flow increases secondary to vasodilatation of the cavernosal arteries
•
Relaxation of smooth muscle dilates the lacunar spaces causing engorgement
•
Increased intracorporal pressure expands the trabecular wall against the tunica albuginea
•
Compression of the subtunical veins along with a reduction of venous blood flow results in elevated
pressures in the lacunar spaces, “veno-occlusive” mechanism
Flaccid penis - arterial pressure 20mm/Hg
Fully erect - arterial pressure 80-100mm/Hg
Neuroanatomy
The parasympathetic nervous system provides excitatory input causing
vasodilation and erection. (autonomic)
The sympathetic nervous system provides input which results in
detumescence, maintains flaccidity,and emission. (autonomic)
Somatic sensory nerves provide sensation of the penile skin, glans, and
urethra. (dorsal nerve). The motor pathway lies within the sacral
nerves to the pudendal nerve and innervate the bulbocavernous and
ischiocavernous muscles and allow for ejaculation.
Neurovascular Bundle
Putting it all together
Biologic Erections - Adults

Men have 4-5 nocturnal erections

“Maintenance erections”

Each lasting approximately 10 minutes

Typically testosterone dependent

Can be a useful marker to determine psychological vs.
organic ED

But not a replacement for actual sexual activity.
“ The Penis does not obey the order of its master, who tries to erect or shrink it at will. Instead, the
penis erects freely while its master is asleep…….The penis must be said to have its own mind, by any
stretch of the imagination.”
-Leonardo Da Vinci (1504)
Erectile Dysfunction
Defined as the inability to maintain or achieve an
erection for satisfactory sexual intercourse.
May include physiologic, organic, or mixed causes
Prevalence of Erectile Dysfunction among men 40-70
yrs is approximately 52% (minimal 17.2%, moderate
25.2%, and complete 9.6%)
Probability of Erectile Dysfunction increases with age
– and typically associated with other medical
conditions
Massachusetts Male Aging Study:
Feldman HA, et al. J Urol. 1994;151:54-61.
Physiological Causes of Erectile Dysfunction
Hypertension
Depression
Anemia
PVD
Drug abuse
Vascular surgery
Smoking
CAD
Endothelial dysfunction
ED
Alcohol abuse
Hypogonadism
Peyronie’s disease
Trauma/surgery to
pelvis or spine
Endocrine Disorders
Hyperlipidemia
Benet AE, Melman A. Urol Clin North Am. 1995;22:699-709
Physiologic Indicators of ED
Atherosclerosis in narrow
penile arteries may manifest
as ED before becoming
apparent in other arteries.
Detecting atherosclerosis in
1 set of blood vessels
increases the chance of
finding it in other vessels.
Risk Factors: Similar between Heart Disease
and Erectile Dysfunction

Risk factors very similar







smoking
dyslipidemia
hypertension
diabetes
obesity
lack of exercise/sex
Both are vascular conditions
Medications Associated With ED
•
•
•
•
•
•
•
•
•
Estrogens
Antiandrogens
H2-receptor blockers
Anticholinergics
Ketoconazole
Marijuana
Alcohol
Antihypertensives
Narcotics
•
•
•
•
•
•
•
•
•
ß-blockers
Psychotropics
Cigarettes
Cocaine
Spironolactone
Lipid-lowering agents
NSAID’s
Cytotoxic drugs
Diuretics
Benet AE, Melman A. Urol Clin North Am. 1995;22:699-709
Psychogenic vs Organic
Tiefer L, Schuetz-Mueller D. Urol Clin North Am. 1995;22:767-773.
Signs and Symptoms Suggestive of
Psychogenic vs Organic ED
Psychogenic
Organic
Sudden onset
Gradual onset
Complete immediate loss
Incremental progression
AM erections present
Lack of AM erections
Varies with partner and
circumstance
Lack of erections under most
sexually stimulating
circumstances
Adapted from Ralph D, et al. BMJ. 2000;321:499-503.
Patients Who Ask,…

Should we believe a 35 year old that c/o erectile
dysfunction? Yes, evaluation should be part of
any genitourinary history and physical

Remember ED (endothelial dysfunction) or EQ
(erectile quality) = Erectile Dysfunction

What is the role of individual sexual habits?

Don’t treat the age - “Treat the individual”
Case History
45 year old white male presents
with complaints of erectile
dysfunction
Obtain History









When did the problem begin?
Does he have normal sexual desire?
What kind of relationship with partner? (any extramarital
relationships)
Does he have spontaneous erections?
Any recent stress at home or work?
Any past pelvic or lower back surgeries?
Voiding difficulties, hematuria, dysuria, or incontinence?
What type of treatments in the past?
AUA voiding score or recent PSA?
Evaluation
Detail History and Physical
Targeted medical, sexual, and psychosocial history
Physical exam of genitalia
Secondary sexual characteristics
Check for penile abnormalities
Check for groin and peripheral pulses
Routine laboratory :
screening for diabetes, liver disease, or renal disease, testosterone
(prolactin level if testosterone low) Fasting lipids, glucose, and androgens
Specialized testing:
Nocturnal Penile Tumescence (NPT can differentiate b/w
psychogenic vs organic ED ) Color Doppler imaging ( minimally invasive
way to identify vascular ED)
Sexual Health Inventory for Men
5-Item questionnaire:
SHIM Score Correlates ED Severity

Erection confidence
•22-25
Normal erectile function

Erection firmness
• 17-21
Mild ED

Maintain erection
• 12-16
Mild-to-moderate ED

Maintain to completion
• 8-11
Moderate ED
• 7
Severe ED

Intercourse satisfaction
Rosen RC, et al. Int J Impot Res. 1999;11:319-326.
Treatment of Erectile Dysfunction
Non – Invasive Therapy:

Psychotherapy

Oral PDE-5 Inhibitors


Invasive Therapy:

M.U.S.E (meatal urethral
suppository for erection)

Alprostadil cavernosal injection

Penile revascularization

Penile prosthesis – malleable or
inflatable
Vacuum Erection device
Testosterone supplementation
Psychosocial Counseling :
First-Line Therapy

Useful as monotherapy or as adjunctive
treatment and may include:

Communication training for couples

Anxiety reduction/desensitization

Cognitive-behavioral interventions

Sexual stimulation techniques
Rosen RC. Urol Clin North Am. 2001;28:269-278.
Vacuum Erection Device




Cylindrical vacuum pump placed over the penis.
Air is drawn from the cylinder, causing blood to
flow into the penis
Occlusive ring is placed around the penile base
to maintain the erection
Maximum duration of use: 20-30 minutes
Complications include penile pain, penile
bruising, hematoma
Testosterone Supplementation



Not indicated in men with normal testosterone
levels
Indications include: libido, energy, muscle
strength, erectile dysfunction, and osteoporosis
Literature now controversial in regards to
testosterone supplemation in men with
increased PSA and even diagnosed prostate
cancer
Alprostadil Delivery
MUSE (Medicated Urethral System
for Erection)
•
•
•
Erection begins 5-20 minutes after
administration
Must use a condom barrier
Side effects: burning of genitals or urethra,
urethral bleeding, priapism, hypotension
Intracavernosal Injections



Trimix/Bimix: refers to mixture containing 2 or
2 of the following agents: papaverine,
phentolamine, alprostadil
Side effects: pain, penile fibrosis, priapism
Patient must be taught in office and observed
when initiating treatment of either MUSE or
injection therapy
Penile Prosthesis: Realistic Expectations ?
Placement of Penile Prosthesis
Type 5 Phosphodiesterase (PDE5)
Inhibitors

Viagra (Sildenafil) Tabs: 25, 50, 100 mg.

Levitra (Vardenafil) Tabs: 2.5, 5, 10, 20 mg.

Cialis (Tadalafil) Tabs: 5, 10, 20 mg.
Clinical Benefits of PDE5 Inhibitor Therapy

Can be taken orally

Well tolerated by most patients

High success rate when used appropriately

Effects of drug are reversed once drug is discontinued

Results in natural erection

Long term data suggests certain class of medications
can be used with continued success
Lowering of Ca++
Smooth muscle relaxation
PI Data: High Fat Meal

Viagra…when taken
with a high fat meal,
the rate of absorbtion
is reduced, and mean
delay in Tmax of 60
minutes

Levitra…as with Viagra,
high fat meal affects
absorbtion, 4 hour effect
(same as Viagra)

Cialis – No effect on
Cmax or Tmax, 36
hour effect
PI Data: Side Effect Profile
Sildenafil
Vardenafil
Tadalafil
Headache 16%
Headache 15%
Headache 15%
Flushing 10%
Flushing 11%
Flushing 3%
Dyspepsia 7%
Dyspepsia 4%
Dyspepsia 10%
Nasal congestion 4%
Nasal congestion 9%
Nasal Congestion 3%
Blue vision 3%
Blue vision <2%
Back pain 6%
Myalgia 3%
Limb pain 3%
Excellent PDE5 Selectivity
PDE6—retina (1:10)
PDE1—vasculature,
heart, brain (1:80)
PDE3—heart (1:4600)
PDE11—heart, pituitary,
testes (1:780)
PDE5—penis (1:1)
Gbekor E, et al. Poster presented at: European Association of Urology; February 23-26, 2002; Birmingham, United Kingdom.
Myalgia and Back Pain Effects: Tadalafil

No CPK changes

No rhabdomyalgia

Recommended to take anti-inflammatory for
those patients that c/o symptoms

Over 10% combined side effect

Leading cause of discontinuation
PI Data: Alpha-blocker Issue
• Levitra:
• contraindicated with ALL alpha-blockers
• Tadalafil:
• Previously contraindicated with ALL alpha-blockers except for
0.4mg dose of Flomax
• Sildenafil:
• Precaution only pertains to Doxazosin (Cardura) and Terazosin
(Hytrin), not Tamsulosin (Flomax).
• Viagra doses above 25 mg’s should not be taken within 4 hours of
taking an alpha-blocker.
Recently the FDA removed any contraindication with PDE 5 inhibitors, however patients
should be counseled on potential interactions
What do we know?

Clinical Data:
 Sildenafil



> 7 years of clinical experience
Prescribed by more than 600,000 Physicians to >23,000,000
patients
More than 2000 published abstracts, papers, reviews,
commentaries, and supplement papers
 Vardenafil

Limited data to date on LONG term effectiveness, some QT
interaction
 Tadalafil

Limited data to date on LONG term effectiveness, very long halflife
Sildenafil Efficacy With Prolonged Duration
of Therapy
Patients reporting
Improved Erections (%)
100
90
80
70
60
50
40
30
20
10
0
2
4
8
12
20
Weeks of Treatment
n=264-331
W Steers, et.al., Int Journ of Impotence Research. 2001; 261-267.
28
36
Why Do Patients Discontinue PDE5 Inhibitors

Lack of adequate education and preparation

Unrealistic patient expectations

Partner’s resistance to medication
 Safety concerns
 Negative attitude

Prolonged sexual inactivity

Loss of desire for sex

E.D. unresponsive to oral medical therapy
Post Prostatectomy Erectile
Dysfuntion




Potency results following radical retropubic
prostatectomy with bilateral nerve sparing vary
widely
At major centers with experienced surgeons the
range is 40%-86%
Most urologists rarely report potency rates
higher than 40%
Factors include age, pre surgical erectile function
Post Prostatectomy Erectile
Dysfunction




Function of any smooth muscle is dependent on tissue
oxygenation
Penile hypoxia is the key factor in collagen deposition
Nightime erections have been implicated in preserving
normal erectile funtion by providing regular tissue
oxygenation
The lack of any erections after nerve damage from
surgery may be the cause of penile hypoxia and fibrosis
formation
Post Prostatectomy Erectile
Dysfunction
Nerve damage from radical retropubic
prostatectomy may last up to a year
 Robotic surgery and post operative
potency results look incredibly promising

Robotic Operations
 Small
 3-D
incisions
vision
 Enhanced
dexterity/no tremor
 Instrument
wrist motion
 Comfortable
position for surgeon
Da Vinci Robotic System
Post Prostatectomy Erectile
Dysfunction Treatment Options

Pharmacologic Agents
 Daily or 14-20 days/month
 PDE-5 inibitors
 Injection therapy three times a week
 Intraurethral alprostadil three times a week
(MUSE)
Post Prostatectomy Erectile
Dysfunction Treatment Options

Non-pharmacologic agents
 Vacuum Erection device: daily for 5-10
minutes
 Combination of above pharmacologic and
non-pharmacologic treatments
Post Prostatectomy Erectile
Dysfunction Treatment Options


Current literature recommends early penile
rehabilatation with Vacuum Erection Device and
PDE-5 inhibitors
Most user friendly, cost effective, and patient
compliant
Thank you for attending
Jeffrey Spier M.D