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