Erectile Dysfunction BY Ahmed Mahmoud Riad Overview Definition

Erectile Dysfunction BY Ahmed Mahmoud Riad

Overview • • • Definition Anatomy and Physiology History Examination Investigations Treatment

Definition of ED • Persistent inability to attain and maintain a penile erection adequate for satisfactory sexual performance. • It affects more than 150 million men all the world.

Anatomy and Physiology of erection • Sexual stimulation triggers a cascade of events. • Erection is neurovascular phenomena combining neurotransmission and vascular biologic responses. • Release of neurotransmitters that result in smooth muscle relaxation in both penile erectile tissue and the penile arterial walls • This transforms the penile vasculature and erectile tissues from contracted, minimally perfused state to relaxed engorged state.

Anatomy and Physiology of erection Reproduced from Carson C, Holmes S, Kirby R. Fast Facts- Erectile Dysfunction. Oxford: Health Press Limited; 2002: 8

Anatomy and Physiology of erection • The limbic system, part of cerebral cortex from which stimulation can elicit erection. • Medial preoptic area and paraventricular nucleus of hypothalamus are high integration centers for sexual drive and erection. • Parasympathetic nerves S 2 -4 mediate erection • Sympathetic nerves T 11 -L 2 control ejaculation and detumescence. • Somatic nerves S 2 -S 4 mediate sensation and motor to ischiocavernosus and bulbocavernosus muscles.

• Smooth muscle relaxation ▫ Nitric oxide diffuses into cavernosal smooth muscle cells, activates Guanylate cyclase converts guanosine triphosphate to c. GMP resulting in smooth muscle relaxation. Effect of c. GMP stopped by Phosphodiesterase type 5 which exists primarily in corpora cavernosa.

Veno-occlusive Mechanism Reproduced from Carson C, Holmes S, Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 12

History • • • Detailed description of problem, is it ED? Causative factors Sexual desire/libido Ejaculatory disorders Impact on quality of life and on relationship Expectations of treatment

Clues differentiating psychogenic from organic causes • Psychogenic ▫ Sudden onset ▫ Situational ▫ Normal waking and nocturnal erections ▫ Normal erection with masturbation ▫ Relationship problems ▫ Life event ▫ Anxiety, fear, depression • Organic ▫ Gradual onset ▫ All situations ▫ Reduced or absent waking and nocturnal erections ▫ No erection with masturbation ▫ Penile pain

Relationship issues • • Current relationship status Length of relationship Previous sexual partners and relationships Partner issues e. g. menopause/pain/cancer

History • • Medical Surgical Psychiatric Medication Smoking Alcohol Recreational drug use

Arteriogenic Cause of ED • • Hypertension Smoking Diabetes Hyperlipidaemia Peripheral vascular disease Blunt perineal or pelvic trauma Pelvic irradiation

Neurogenic causes of ED • Lesions of medial preoptic nucleus, paraventicular nucleus, hippocampus • Spinal trauma • Myelodisplasia (spina bifida) • Pelvic surgery/radiotherapy • Multiple sclerosis • Intervertebral disc lesion • Peripheral neuropathies ▫ Alcohol ▫ Diabetes ▫ HIV

Psychogenic and Psychiatric causes • • • Anxiety Loss of attraction to partner Relationship difficulties Stress Depression

Psychogenic ED Reproduced from Carson C, Holmes S, Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 33

Endocrine causes of ED • Hypogonadism ▫ Low testosterone ▫ Raised SHBG ▫ Raised Prolactin • Thyroid disease

Drugs associated with ED • Antihypertensives ▫ Thiazides ▫ B blockers ▫ Centrally acting drugs • Antidepressants ▫ Tricyclics ▫ MAO inhibitors ▫ SSRI • Anticholinergics ▫ Atropine • Antipsychotics ▫ Phenothiazines • Anxiolytics ▫ Benzodiazepines • Psychotropic drugs ▫ ▫ Alcohol Opiates Amphetamines Cocaine

Examination • • • Blood pressure Peripheral pulses Testes size and consistency Secondary sexual characteristics Penis for Peyronie’s plaques

ED and Coronary Artery Disease • • Generalised atherosclerosis Penile arteries smaller than coronary arteries ED pre-dates coronary artery disease Man with ED and no cardiac symptoms is a cardiac patient until proven otherwise

Investigations • Fasting glucose and lipids • Morning testosterone and SHBG • If testosterone is low or borderline repeat with Prolactin, FSH and LH • Thyroid function

Specialised Investigations • Vascular studies ▫ Young patients with primary ED ▫ History of trauma e. g. penile fracture ▫ Patients unresponsive to medical therapies

Treatment of ED General Measures • • Smoking cessation Reduce alcohol Weight loss Exercise

Endocrine Disorders • • Hypogonadism Hyperthyroidism Hyperprolactinaemia Endocrinology referral

Psychosexual therapy • Even if cause of ED is physical the patient will develop psychosexual issues • Performance anxiety • Sensate focus exercises • Relationship counselling

Drugs for ED • Oral agents ▫ Centrally acting dopamine-receptor agonist Apomorphine (discontinued in UK) ▫ Phosphodiesterase type 5 inhibitors • Intra-cavernosal ▫ Prostaglandin E 1 Alprostadil • Intra-urethral ▫ Alprostadil

PDE 5 inhibitors • Sildenafil (Viagra) 25 mg, 50 mg, 100 mg ▫ 1 hour before sexual activity ▫ 4 -6 hour window ▫ Absorption delayed by fatty meal • Tadalafil (Cialis) 10 mg, 20 mg ▫ 30 minutes before sexual activity ▫ 36 hour window ▫ Absorption not affected by food • Tadalafil (Cialis) 5 mg ▫ daily • Vardenafil (Levitra) 5 mg, 10 mg, 20 mg ▫ 30 -60 minutes before sexual activity ▫ 4 -6 hour window ▫ Absorption delayed by fatty meal

PDE 5 Physiology Reproduced from Carson C, Holmes S, Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 40

PDE 5 Inhibitors Side Effects • • Facial flushing Headache Nasal congestion Dizziness Dyspepsia Visual disturbance (blue halo) Priapism Non-arteritic anterior ischaemic optic neuropathy

PDE 5 Contraindications • • Recent cardiovascular event Nitrates Hypotension Anatomical deformity ▫ Angulation, cavernosal fibrosis, Peyronie’s • Predisposition to prolonged erection ▫ Sickle cell disease ▫ Multiple myeloma ▫ Leukaemia

PDE 5 Drug Interactions • Nitrates ▫ Glyceryl trinitrate, isosorbide mono or dinitrate ▫ Chest pain after taking Sildenafil/Vardenafil no nitrates 24 hours, Tadalafil no nitrates 48 hours ▫ Recreational amyl nitrate (Poppers) • Cytochrome P 450 inhibitors ▫ Protease inhibitors especially Ritonavir use very small dose ▫ Cimetidine, Ketoconazole, Erythromycin • Alpha blockers

Intracavernosal Injections • Alprostadil (Caverject, Viridal) 5 -40 mcg ▫ Independent of intact nervous system ▫ Manual dexterity, adequate vision, training ▫ Contraindicated: bleeding disorders, sickle cell anaemia, multiple myeloma, leukaemia ▫ Side effects: penoscrotal pain, haematoma, fibrosis at injection sites, priapism • Papaverine, Phentolamine, Aviptadil (vaso-intestinal peptide) been used sole or with Alprostadil

Intracavernosal Injections Reproduced from Carson C, Holmes S, Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 53

Intraurethral • Alprostadil (Muse) 125 mg, 250 mg, 500 mg, 1 g ▫ Pellet inserted with applicator ▫ Massage penis to aid absorption ▫ Side effects: Penile pain, dizziness, priapism rare

Intraurethral Alprostadil Reproduced from Carson C, Holmes S, Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 55

Vacuum Devices • Blood trapped in intracorporal and extracorporal compartments of penis • Constricting ring at base of penis • Cyanosis, oedema, cold • Pivots at base below ring • Maximum time 30 minutes

Vacuum devices Reproduced from Carson C, Holmes S, Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 61

Penile Prostheses • • Semi-rigid rods 2 piece inflatable prosthesis 3 piece inflatable prosthesis with abdominal reservoir Risks ▫ ▫ Infection Destroys corpora cavernosa Erosion and extrusion Mechanical failure

Penile Prosthesis Reproduced from Carson C, Holmes S, Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 66

NHS Prescription for ED • • Diabetes Multiple sclerosis Parkinson’s Disease Poliomyelitis Prostate cancer Prostatectomy incl TRP Radical pelvic surgery Severe pelvic injury • Renal failure ▫ On dialysis ▫ Transplant • Single gene neurological disease • Spinal cord injury • Spina bifida • Receiving NHS Rx 14/9/1998 • Severe distress

Conclusions • • ED is a common problem Impact on patient and partner/s Overlap of psychological and physical May be initial presentation of diabetes or coronary artery disease • Good range of safe and effective therapies • If YOU don’t ask your patient may be too embarrassed to tell you