Ann Marie Johnson

1. Ann Marie Johnson HCA Conference September 2015

2. HCA role • 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.

3. 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?

4. 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.

5. 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.

6. 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

7. Predictors of longevity difference :A 25 year followup • 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

9. 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.

10. 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

11. Causes of Erectile Dysfunction • Tobacco addiction • Neurological disease • Diabetes • Hardening of the arteries • Depression • Testosterone Deficiency Syndrome • High blood pressure • Lack of thyroid hormone • Alcoholism • Kidney/liver disease

12. Major causes of erectile dysfunction Endocrine disorders 6% Multiple Sclerosis 3% Spinal Cord Injury 8% Diabetes Mellitus 40% Radical Surgery 13% Vascular Disease 30%

13. Neurological causes of ED • Spinal cord-high complete lesion-psychogenic 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.

14. Psychological or Physical • Psychological • Sudden onset • Specific situation • Normal nocturnal and Morning erections • Relationship problems • Problems during sexual development • Physical • Gradual onset • All circumstances • Absent nocturnal and early morning erections • Normal libido and ejaculation • Normal sexual development

15. Relationship of T levels to symptoms Total testosterone nmol/L Patients (n) 74 20 69 15 Increasing prevalence of symptoms with decreasing androgen concentrations 84 12 65 10 67 8 In 434 male patients aged over 50 years 75 0 Zitzmann et al. JCEM 2006

16. 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

17. 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 inflammatoryactivation (TNF & IL) • Improves diabetic control • Increases Hb in CCF Kapoor D Eur J Endocrinol 2006;154:899-906

18. 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

19. 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

20. Grade 1

21. Grade 2

22. Grade 3

23. Grade 4

24. 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

25. 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.

26. Veno-Occlusive Mechanism in Penile Erection Vascular valves open venous efflux flaccid Tunica Albuginea subtunical “compartment” Vascular valves close arterial Influx Firm erection venous efflux

27. Veno-Occlusive Mechanism in Penile Erection venous efflux flaccid Tunica Albuginea Vascular leakage subtunical “compartment” No firm erection arterial Influx

28. Treatments for Erectile Dysfunction • Oral medications-Phosphodiesterase type 5 Inhibitors- PDE5 -Viagra-Sildenfil, Levitra-Vardenafil, Cialis-Tadalafil, 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

29. 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

30. 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!

31. 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.

32. Getting started • Cialis-Tadalafil 10mg, 20mg yellow tablet • Different to previous two, longer half life so it lasts for 24-36 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.

33. Alternative therapies-if oral drugs are not suitable • Intercavernosal injections, erection occurs 5-20minutes 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

34. 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.

35. 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 disorders-bruising 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

36. ED: BAROMETER OF MEN’S HEALTH: The Deadly Quartet Hypertension Dyslipidemia Obesity Diabetes

39. Atherosclerosis in Coronary Vessels Atherosclerosis in Penile Arteries

40. 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

41. 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.

42. Early Detection-health check Early Death Endothelial Dysfunction-risk factors Education -lifestyle Erectile Dysfunction Take Home Message E.D.

43. Is your willy working? • If not your heart may be in trouble too • Seek medical help – it may save your life

44. 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”