Erectile Dysfunction

1. Erectile Dysfunction HDR Peer Presentation Pennine Training Scheme Dr Lorna Clark, GPST

2. What is Erectile Dysfunction • Synonym: Impotence • Inability to attain and maintain an erection sufficient for satisfactory sexual performance • Benign • Significant impact on quality of life

3. Epidemiology • Incidence and prevalence is high worldwide • Effects up to 52% of men (40-70yrs) • Steep age-related increase. Complete impotence from 5% of 40yr olds to 15% of 70yr olds • Only 10-20% solely psychogenic

4. Risk factors Note shared risk factors with CVD: • Sedentary lifestyle • Obesity • Smoking • Hypercholesterolaemia • Metabolic syndrome • Diabetes mellitus

5. Aetiology • Organic • Hormonal • Anatomical • Drugs • Psychogenic

6. Organic causes • Vascular factors (CVD, atherosclerosis, hypertension, diabetes, hyperlipidemia, smoking, trauma) • Central causes (Parkinson’s, stroke, MS, tumours, spinal disease/injury) • Peripheral causes (poly-/peripheral neuropathy, diabetes, alcoholism, uraemia, pelvic surgery

7. Hormonal causes • Hypogonadism • Hyperprolactinaemia • Thyroid disease • Cushing’s disease

8. Anatomical causes • Peyronie’s disease • Micropenis • Penile anomalies (hypospadias etc)

9. Drugs • Antihypertensives (beta blockers, diuretics) • Antidepressants (tricyclic and SSRIs) • Antipsychotics (phenothiazines, risperidone) • Anticonvulsants (phenytoin, carbamazepine) • Antihistamines • H2 antagonists (cimetidine, ranitidine) • Recreational drugs (inc tobacco and alcohol)

10. Psychogenic Causes • General (disorders of intamacy, lack of arousability) • Situational (partner, performance, stress) • Psychiatric illness (Anxiety states, depression, psychosis, alcoholism)

11. Taking a history • Take an understanding approach • Sexual history – International Index of Erectile Function questionnaire (IIEF) • Current and Past sexual partners • Current emotional state • Erectile symptoms (onset and duration) • Previous problems, advice and treatments • Quality of erections (erotic and morning) • Arousal, ejaculation and orgasm difficulties • General medical/past medical history and medications

12. History suggesting organic cause • Gradual onset • Normal ejaculation • Normal libido • Medical risk factor • Trauma/surgery/radiotherapy to pelvis • Current medication • Lifestyle

13. History suggesting psychogenic cause • Sudden onset • Early collapse of erection • Self stimulated or waking erections • Premature ejaculation or inability to ejaculate • Problems/change in relationship • Major life event • Psychological problems

14. Examination • Genitourinary examination (anatomical abnormalities, size of testes) • Pulses (femoral), BP • Rectal examination (over 50yrs)

15. Investigation • Bloods: Fasting glucose, lipids, U&Es, LFTs, TSH, Early morning serum testosterone (plus FSH and LH if testosterone low) • Haemoglobinopathy screen (sickle cell) in afro-caribbean patients • Dipstick urinalysis • Vascular studies (duplex ultrasound cavernous arteries, arteriography, intracavenous vasoactive drug injection) • Neurological studies • Specialist psychodiagnostic evaluation

16. Indications for referral • Endocrine abnormality • Young patients with trauma • Penile disorder/abnormality • Complex cases • Patient/partner request for specialist tests/treatment

17. Management • Main goal: diagnose and treat underlying cause • Modify reversible causes (lifestyle, drugs). Men who initiated physical exercise and weightloss have upto 70% improvement (note: cycling more than 3 hours per week may cause dysfunction)

18. Treatment • Hormonal: testosterone failure – give testosterone • Post-traumatic arteriogenic: surgery • Psychogenic: underlying problem, sex therapy/counselling, phosphodiesterase type-5 inhibitors (sildenafil, tadalafil, vardenafil)

19. First-line treatment – oral therapy • PDE-5 inhibitors improve relaxation of smooth muscle. Contraindicated in patients receiving nitrates, recent stroke/MI, unstable angina • Sildenafil: well tolerated, efficacy reduced after fatty food, 50mg starting dose • Tadalafil: longer half-life, start at 10mg • Vardenafil: more potent (but not clinically more effective), useful in difficult to treat subgroups, effect reduced by fatty food. • Apomorphine hydrochloride: dopamine agonist, quick action, sublingual, not effected by foods

20. Treatment: Vacuum devices • External cylinder, pumping air out around penis and causing engorgement • Clinical success rate of 90% • Work best: motivation, supportive partner • Adverse effects: pain, petechiae, bruising, numbness

21. Second line treatments • Intraurethral alprostadil (prostaglandin E1): insert pellet urethral meatus, barrier contraception if partner pregnant, less effective than intracavernous injections, may cause penile pain • Intracavernosal alprostadil: injected, may cause pain and priapism (refer urgently to hospital for blood to be drained)

22. Third-line treatment • Penile prosthesis: semi-rigid, malleable or inflatable. Considered if impotence has organic cause and fail to respond to medical management • Topical agents: some vasoactive drugs come in topical gel form, may suffer local reaction and side-effects to partner if absorbed from vagina.

23. Prescription advice • Medications only to be prescribed on NHS if: diabetes, MS, Parkinson’s, poliomyelitis, prostate cancer, severe pelvic injury, spina bifida, spinal cord injury, receiving dialysis, history of radical pelvic surgery/prostatectomy/renal transplant, or receiving treatment before September 1998 • Should also be available if dysfunction causing severe distress (significant disruption to normal social activities, interpersonal relationships and effecting mood, behaviour etc)