ERECTILE DYSFUNCTION FOR THE GENERALIST ERECTILE DYSFUNCTION DEFINITION

ERECTILE DYSFUNCTION ______________ FOR THE GENERALIST

ERECTILE DYSFUNCTION ______________ DEFINITION THE PERSISTENT INABILITY TO ACHIEVE OR MAINTAIN ERECTION SATISFACTORY FOR SEXUAL PERFORMANCE

SCOPE AND IMPACT _____________ ERECTILE DYSFUNCTION • 30 MILLION MEN IN THE USA • 40% PREVALENCE AMONG MEN > 40 • 70% PREVALENCE AMONG MEN > 70

Anatomy and Mechanism of Penile Erection

Molecular Mechanism of Penile Smooth-Muscle Relaxation

Molecular Mechanism of Penile Smooth-Muscle Contraction

HISTORY-TAKING ERECTILE DYSFUNCTION • • SEQUENCE DICTION ATTITUDE LEVEL OF DETAIL

HISTORY-TAKING OVERCOMING RETICENCE ERECTILE DYSFUNCTION • ASSURE CONFIDENTIALITY • UNIVERSALIZE • EMPATHIZE

HISTORY-TAKING USE THE PHASES OF THE SEXUAL RESPONSE CYCLE TO GUIDE YOUR INQUIRY • • DESIRE EXCITEMENT ORGASM RESOLUTION

HISTORY-TAKING ERECTILE DYSFUNCTION PSYCHOGENIC ORGANIC Abrupt Gradual Course Selective Persistent Degree Partial Absolute Yes No Psychosocial stress Organic Disease Onset Nocturnal or am Erection? Associated Features

DIAGNOSIS ERECTILE DYSFUNCTION • • HISTORY IS (almost) ALL PHYSICAL CONSIDER SERUM TESTOSTERONE OTHER TESTS USUALLY NOT INDICIATED

DIAGNOSIS ERECTILE DYSFUNCTION • • R/O HORMONAL ETIOLOGY R/O SUBSTANCE ABUSE CONSIDER PSYCHOGENIC ETIOLOGY CONSIDER MEDICATION CHANGES TRY TREATMENT

Approach to the Diagnosis and Treatment of Erectile Dysfunction

Molecular Mechanism of Penile Smooth-Muscle Relaxation

PRESCRIBING

PRESCRIBING • Start with medium dose • Minor side effects – headache, flushing, dyspepsia, nasal discharge, visual change • Consider cost and insurance coverage

DEATH BY VIAGRA? ________________ SAFETY • • REPORT TO FDA EXPECTED DEATHS PER SECOND HEMODYANIC STUDIES AHA GUIDELINES

Deaths Associated with Sildenafil Therapy in the United States

Other Oral Meds ERECTILE DYSFUNCTION • • Yohimbine Trazodone Apomorphine Phentolamine

Approach to the Diagnosis and Treatment of Erectile Dysfunction

Tranurethral Medication ERECTILE DYSFUNCTION • • Alprostadil = Muse = Prostaglandin E 1 Moderate Efficacy Expensive Causes pain frequently

Mechanical Aids ERECTILE DYSFUNCTION • Vacuum device • Constriction rings

Intracavernosal Therapy ERECTILE DYSFUNCTION • “Trimix” of alprostadil, phentolamine, papaverine • Almost always efficacious • Requires referral, training, careful monitoring • Risk of priapism and fibrosis

Penile Prostheses ERECTILE DYSFUNCTION • • • Effective Major surgery Expensive Significant risk of infection Usually have to be replace after 5 -10 years

Treatment Options for Men with Erectile Dysfunction