Erectile DysfunctionTom Havard

2013

Great Western Hospital

GPST Teaching

History

Impotentia coeundi

Chinese 2500BC: Yin-Yang, herbs, acupuncture.

Egyptians 1600BC: Ground crocodile hearts, lotus flowers aphrodisiac (apomorphine)

300BC-1800s: Spanish Fly (cantharidin). Augustus Caesar, Henry IV, Marquis De Sade

1200s: Witchcraft

1873: First surgical treatment, blocking veins.

History

1918: Implanting monkey testicle, then cadavers, goats, boars, deer.

Early 20th Century: Electric shock treatment.

1935 Holland: Discover Testosterone.

1960s: Penile implants

1970s: Penis pumps

1980s: Injections

1994: Viagra

Erectile Dysfunction

Inability to initiate or maintain an erection to ejaculation.

Erection: in tact parasympathetic reflex S2, S3.

Ejaculation: in tact sympathetic L1 root.

Aetiology

Blood Supply

Hormones

Nerves

Psychological

Hormones

Blood Supply

70%

Aetiology

Spinal cord or cauda equina

Stroke

PD

MS

Traumatic nerve/vascular damage: eg radical prostatectomy, pelvic #

HTN,

SSRIs, antihypertensives

Smoking

Leriche Syndrome

Hypogonadism

Peyronies

Diabetes

Depression, anxiety, stress

Cycling

Epidemiology

Affects 52% aged 40-70

10% complete ED

70% age >70yrs

Those with ED twice as likely to have MI, 20% higher chance of admission with heart failure, 10% more likely to have stroke

History

When, How…

Early morning erections

Anxieties about sexual matters

Organic causes

Diabetes, EtOH, Drugs,

Relationships, conflicts, communication

Depression

Investigations

Bloods

Glucose

Testosterone, Prolactin

TFTs

Lipids

Routine

Treatment

Dependent on cause

Psychological therapy to reduce anxiety, involving partner

Lifestyle change shows improvement in sexual function in one third of obese men

Drugs

PDE5 Inhibitors thus increasing

cGMP and interaction with NO

Sildenafil (Viagra)

Tadalafil (Cialis)

Vardenafil (Levitra)

Also used for pulmonary HTN

(Revatio), Altitude sickness, mixed

with illicit drugs (beware amyl nitrate),

cut flowers.

Eligible on NHS

Diabetes

MS

Parkinsons

Poliomyelitis

Prostate Ca

Prostatectomy incl TURP

Radical pelvic surgery

Renal failure treated by

dialysis or transplant

Severe pelvic injury

Single gene neurological disease

Spinal cord injury

Spina bifida

Receiving Tx 14/09/98

Impotence causing severe distress (after hospital assessment)

Contraindications

Organic nitrates

Hypotension <90/50. Careful use with alpha blockers

Severe hepatic impairment

Hereditary degenerative retinal disorders eg retinitis pigmentosa

Recent stroke or MI

Careful use with other

P450 inhibitors eg

cimetidine

Sublingual Apomorphine

Dopamine agonist

Not as effective as Sildenafil

Only licensed oral drug not absolutely contraindicated for use with nitrates

Positive response in 40-50% patients

Intracavernosal Injections

Alprostadil, Prostaglandin E1 causes vasodilation

Effective in up to 80%

Few contraindications or interactions

Requires training, manual dexterity,

eyesight

Pain on injection

Also used to maintain patent

ductus arteriosus

Transurethral Alprostadil

Effective in 10mins, lasts 20-60mins

Less effective than intracavernosal and slower acting, but less incidence of priapism

Vacuum Devices

Plastic cylinder, vacuum created by hand or electric pump

Constriction ring around base of penis

Reported long term success in up to

60% of patients

Penile Prostheses

Two types

Malleable pair of rods with metal core

Inflatable cylinders with internal

pump and reservoir

For patients that have failed to

respond to other treatments or have

developed fibrosis

Risk of infection, erosion through the

glans

Clinical Evidence Review

Evidence of benefit:

Alprostadil (both intracavernosal and transurethral), Apomorphine, Sildenafil, Tadalafil, Vardenafil

Likely to be beneficial:

Ginseng, prosthesis, psychosexual counselling, vacuum devices, yohimbe bark

Referral From Primary CareUrology

Young men that have always had difficulty

Hx of trauma (genitals, pelvis, spine)

Clinical abnormality (micropenis, peyronies)

Fail to respond to at least 2 max dose PDE5 Inhibitors

Endocrinology

Hypogonadism, abnormal testosterone,

prolactin

Cardiology

Disease making sex or PDE5 use unsafe

Psychologists

SummaryCommon – 52% aged 40-70

Multiple causes

Take comprehensive history

Investigate cardiovascular disease

Consider psychological management

Multiple treatments – First line Sildenafil

Check if qualifies for NHS treatment and contraindications

Refer as approprtiate