Post on 13-Jan-2016
ERECTILE DYSFUNCTION
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FOR THE GENERALISTFOR THE GENERALIST
ERECTILE DYSFUNCTION
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DEFINITIONTHE PERSISTENT INABILITY TO ACHIEVE OR MAINTAIN ERECTION SATISFACTORY FOR SEXUAL PERFORMANCE
SCOPE AND IMPACT__________________________
ERECTILE DYSFUNCTIONERECTILE 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 DYSFUNCTIONERECTILE DYSFUNCTION
• SEQUENCE
• DICTION
• ATTITUDE
• LEVEL OF DETAIL
HISTORY-TAKING
OVERCOMING RETICENCE ERECTILE DYSFUNCTIONERECTILE DYSFUNCTION
• ASSURE CONFIDENTIALITY
• UNIVERSALIZE
• EMPATHIZE
HISTORY-TAKING
USE THE PHASES OF THE SEXUAL RESPONSE CYCLE
TO GUIDE YOUR INQUIRY
• DESIRE
• EXCITEMENT
• ORGASM
• RESOLUTION
HISTORY-TAKINGERECTILE DYSFUNCTIONERECTILE DYSFUNCTION
PSYCHOGENIC ORGANIC
Onset Abrupt Gradual
Course Selective Persistent
Degree Partial Absolute
Nocturnal or am Erection?
Yes No
Associated
Features
Psychosocial stress
Organic Disease
DIAGNOSIS ERECTILE DYSFUNCTIONERECTILE DYSFUNCTION
• HISTORY IS (almost) ALL
• PHYSICAL
• CONSIDER SERUM TESTOSTERONE
• OTHER TESTS USUALLY NOT INDICIATED
DIAGNOSIS ERECTILE DYSFUNCTIONERECTILE 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 DYSFUNCTIONERECTILE DYSFUNCTION
• Yohimbine
• Trazodone
• Apomorphine
• Phentolamine
Approach to the Diagnosis and Treatment of Erectile Dysfunction
Tranurethral Medication ERECTILE DYSFUNCTIONERECTILE DYSFUNCTION
• Alprostadil = Muse = Prostaglandin E1
• Moderate Efficacy
• Expensive
• Causes pain frequently
Mechanical Aids ERECTILE DYSFUNCTIONERECTILE DYSFUNCTION
• Vacuum device
• Constriction rings
Intracavernosal Therapy ERECTILE DYSFUNCTIONERECTILE DYSFUNCTION
• “Trimix” of alprostadil, phentolamine, papaverine
• Almost always efficacious
• Requires referral, training, careful monitoring
• Risk of priapism and fibrosis
Penile Prostheses ERECTILE DYSFUNCTIONERECTILE 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