Evaluation and Treatment of Erectile Dysfunction

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Evaluation and Treatmentof Erectile Dysfunction

• Michael P. Finkelstein, M.D.

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• Man survives earthquakes, experiences the
  horrors of illness, and all of the tortures of
  the soul. But the most tormenting tragedy of all
  time is, and will be, the tragedy of the
  bedroom.
• Tolstoy

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Goals and Objectives

• Define erectile dysfunction (ED)
• Discuss the most common causes of ED
• Review a practical evaluation of men with ED
• Review the treatment options
• Provide suggestions for urologic referral

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What is ED?

• ED is the inability to achieve and maintain an
  erection adequate for intercourse to the mutual
  satisfaction of the man and his partner.
• Remember, both partners in a relationship are
  affected.

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Incidence

• 20-30 million American men suffer ED
• Age dependent
• 2 men age
• 25 men age 65
• 75 men 75 years
• Not a necessary occurrence of the aging process

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How Does an Erection Occur?

• The brain controls all sexual functions, from
  perceiving arousal to initiating and controlling
  the psychological, hormonal, nerve, and blood
  flow changes that lead to an erection.
• Hormones, including testosterone, control the
  male sex drive

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How Does an Erection Occur?(cont.)

• Nerve impulses relay signals of arousal and
  sensation to and from the penis
• Arteries deliver extra blood to the penis that
  causes it to stiffen.
• Veins then drain the blood out of the penis after
  intercourse.

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Physical orPsychological Stimuli Results

• Sacral parasympathetics (S2,3,4) stimulation to
  the penile nerves
• Dilation of the penile arteries
• Relaxation of the smooth muscle in the corporal
  bodies of the penis
• Decrease venous outflow

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An Erection Requires a Coordinated Interaction of
Multiple Organ Systems

• Psychological
• Endocrine
• Vascular
• Neurologic

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Mechanism ofSmooth Muscle Relaxation

• Release of Neurotransmitters-nitric oxide
• Conversion of GTP to cGMP - erection
• Breakdown of cGMP by PDE type 5 - detumesence

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Cause of ED

• Psychogenic Causes
• Anxiety
• Depression
• Fatigue
• Guilt
• Stress
• Marital Discord
• Excessive alcohol consumption

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Causes of ED

• Organic Causes
• Cardiovascular disease
• Diabetes mellitus
• Surgery on colon, bladder, prostate
• Neurologic causes (lumbar disc, MS, CVA)
• Priapism
• Hormonal deficiency

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Causes of EDRisk FactorsMassachusetts Male
Aging Study¹

• Treated heart disease 39
• Treated diabetes 28
• Treated hypertension 15
• ¹Feldman Ha, J Urol 1994 15154-61

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Causes of EDOther risk Factors ²

• Diabetes 27 - 59
• Chronic renal failure 40
• Hepatic failure 25 - 70
• Multiple Sclerosis 71
• Severe depression 90
• Other (vascular disease, low HDL, high
  cholesterol)
• ²Benet et al. Urol Clinic North Am. 1995
  15154-61

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Causes of ED

• Hormone Deficiency
• End Organ Failure
• Blockage of Blood Vessels
• Venous Leak

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Causes of ED

• Spinal cord injuries 5 - 80
• Pelvic and urogenital surgery and radiation
• Substance abuse
• Alcohol 600ml/wk
• Smoking amplifies other risk factors
• Medications may be responsible for 25 of cases
  of ED
• Bicycle riding

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Causes of ED

• Medication
• Most common cause of ED in men 50
• Many men are polymedicated
• Also have co-morbid conditions

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Causes of ED

• Medications (cont.)
• Anti-hypertensive drugs
• All capable
• Common thiazides and beta blockers
• Uncommon calcium channel blockers,
  alpha-adrenergic blockers, and ACE inhibitors

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Causes of ED

• Medications (cont.)
• CNS drugs
• Antidepressants, tricyclics, SSRIs
• Tranquilizers
• Sedatives
• Analgesics
• H1 and H2 receptor blockers

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Causes of ED

• Medications (cont.)
• Anticholinergics
• LHRH agonists (Lupron, Zolladex)
• Alcohol
• Tobacco
• Drug abuse
• Estrogens, Ketoconazole

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A Practical Evaluation of Men with EDBasic
evaluation

• Medical History
• Cardiovascular history
• Endocrine history
• Sexual history/questionnaire

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A Practical Evaluation of Men with EDBasic
evaluation (cont.)

• Physical exam
• Focused neurovascular exam
• Size of testis
• DRE
• Lab tests
• UA
• Testosterone, CMP, Lipid panel
• PSA in men 50 years

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A Practical Evaluation of Men with EDSexual
History

• Premature ejaculation
• Retarded ejaculation
• Painful intercourse
• Anorgasmia
• Decreased Libido
• Dissatisfaction with sex life

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A Practical Evaluation of Men with EDSexual
History (cont.)

• Do you have any problems with intimacy with your
  partner?
• Do you have early morning erections?
• Do you have erections with self-stimulation?
• Are you able to consistently obtain and maintain
  an erection sufficient for sexual intimacy?
• Does it hurt to have an erection or intercourse?

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A Practical Evaluation of Men with EDSexual
History (cont.)

• Do you ejaculation sooner than you would like?
• Does it take too long to reach an orgasm?
• Do you fail to reach an orgasm?
• Did your erection problems start suddenly or over
  time?

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A Practical Evaluation of Men with EDED
Questionaire³

• When you had erections with sexual stimulation,
  how often were your erections hard enough for
  penetration?
• How do you rate your confidence that you could
  get and keep an erection?
• ³The International Index of Erectile Function,
  Urol 199749822-830

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A Practical Evaluation of Men with
EDQuestionaire (cont.)

• During sexual intercourse, how often were you
  able to maintain your erection after you had
  penetrated your partner?
• During sexual intercourse, how difficult was it
  to maintain your erection to completion of
  intercourse?
• When you attempted sexual intercourse, how often
  was it satisfactory for you?

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A Practical Evaluation of Men with
EDDifferentiating Psychogenic from Organic ED

• Psychogenic Impotence
• Younger patient (
• Preservation of morning erections and nocturnal
  erections
• Achieve erection with masturbation
• May be partner-specific
• Often sudden onset

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A Practical Evaluation of Men with
EDDifferentiating Psychogenic from Organic ED

• Organic ED
• Gradual deterioration
• Decrease in morning erections and nocturnal
  erections
• No erections with masturbation
• No loss of libido
• Presence of co-morbid conditions

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A Practical Evaluation of Men with EDPhysical
Examination

• Blood pressure
• Examine penis (R/O Peyronies disease)
• Determine size and consistency of testes
• Digital rectal exam
• Focused vascular exam/peripheral pulses
• Focused neurologic exam

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A Practical Evaluation of Men with EDLaboratory
Tests

• UA (glycosuria) Fasting if elevated
• PSA in men over 50
• Testosterone (best to draw in A.M.)
• Prolactin, Thyroid function, Lipid profile, Liver
  function, Creatinine

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A Practical Evaluation of Men with EDOther Tests

• NPT Nocturnal Penile Tumescence Test
• Penile doppler
• Injection of vasoactive drugs
• NEVA (Nocturnal Electobioimpedance Volumetric
  Assessment)

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Treatment OptionsGoal directed therapy4

• Find out what the patient wants
• Try to tailor the treatment to the patients needs
  and wants
• Etiology rarely affects treatment choice for the
  patient
• 4 Lue TF, World J. Urol 867,1990

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Treatment Options

• Nonpharmacologic
• Non-invasive
• Minimally invasive
• Invasive
• Counseling and/or sex therapy

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Treatment Options

• Oral medications - Viagra, Levitra, Cialis
• Urethral suppositories (MUSE)
• Injection therapy - Caverject, Trimix, Bimix
• Vacuum constriction device
• Surgery
• Sex therapy

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Counseling and/or Sex Therapy

• Rule out depression
• Try oral medication in patient with psychogenic
  impotence
• Refer to sex therapist or psychiatrist for sever
  psychopathology

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Nonpharmacologic Treatment Options

• Lifestyle changes
• Reduce fat and cholesterol in diet
• Decrease or limit alcohol consumption
• Eliminate tobacco use and substance abuse
• Weight loss if appropriate
• Regular exercise

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Ideal Medication for Treatment of ED

• Effective
• Available on demand
• Free of toxicity and side effects
• Easy to administer
• Inexpensive

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Medication(Viagra, Levitra, Cialis)

• Mechanism of Action
• PDE inhibitor and increases the cGMP that
  promotes and sustains smooth muscle relaxation

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Medication(PDE Inhibitors)

• Indications
• Psychogenic ED
• Mild vasculogenic ED
• Neurogenic ED
• Side effects from medication(s) patient is
  already taking

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Medication (PDE Inhibitors)

• Side effects
• Headache
• Flushing
• Dyspepsia
• Nasal congestion
• Visual disturbances
• Priapism

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Medication (PDE Inhibitors)

• Contraindications
• Organic Nitrites
• Oral
• Sublingual
• Severe cardiac disease
• Obtain stress testing

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Medication(Yohimbine, Yocon, Erex, Yohimex)

• Alpha 2 andrenoreceptor antagonist
• Dose 5.4 mg TID
• Results 20 (same as placebo)
• Side effects increase blood pressure,
  tachycardia, anxiety

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MedicationTrazodone(Desyrel)

• Anti-depressant associated with priapism
• Mechanism of action nor fully understood
• Nor FDA approved for ED
• Side effects drowsiness, dry mouth, sedation,
  priapism

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MedicationApomorphine (Spontane)

• Dopaminergic mechanism with hypothalamic activity
• Sublingual administration
• 64 to 67 response rate with ED
• Side effects nausea, sweating, hypotension,
  yawning
• Awaiting FDA approval

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MedicationPhentolamine (Vasomax)

• Alpha-blocker
• Relaxes smooth muscle tissue
• 40 efficacy in mild organic ED
• Side effects nasal congestion, tachycardia,
  dizziness, hypotension
• Awaiting FDA approval

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MedicationSide effects

• Discontinue tobacco, alcohol, and abusive drugs
• Alter dosage of drugs with ED side effects
• Change to another class of drugs

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Transurethral TherapyAlprostadil - MUSE

• Mechanism of Action vasodilator
• Administration 125, 250, 500. 1000ug
• Insert in the urethra
• Erection occurs 10-15 minutes later
• Erection lasts 30-45 minutes
• Results 10-65
• Side effects Pain, bleeding, priapism (

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Penile Injection TherapyCaverject, Edex,
Tri/Bi-Mix

• Mechanism of action smooth muscle vasodilator
• Administration 10, 20, 40ug
• Inject directly into corporeal bodies of the
  penis
• Results 70-90
• Dropout rates 25-60
• Side effects pain (36), priapism (4), fibrosis

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Androgen Replacement Therapy

• Indications hypogonadism (
• Avoid oral estrogens-increase LFTs
• Injectable 200mg testosterone (cypionate,
  enathate, propionate), q2-3 weeks
• Transdermal
• Patch
• gel

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Androgen Replacement Therapy

• Avoid in patients with prostate or breast cancer
• Slight increase risk of BPH
• Monitor all patients with annual DRE and PSA

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Vacuum Constriction Device

• Mechanism of Action
• Penis placed in plastic tube
• Air evacuated from the tube
• Blood trapped in penis with constricting ring

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Vacuum Constriction Device

• Erection limited to 30 minutes
• Results 80-90
• Contraindications bleeding disorders, sickle
  cell disease, anticoagulation
• Complications coolness, petechiae, numbness,
  pain with ejaculation
• High drop out rate

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Vacuum Constriction Device

• Was previously first-line treatment for ED
• Seldom used now that oral therapy is available
• Considered an alternative if patient fails oral
  therapy and does not want to proceed with surgery

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Penile Prosthesis

• Indications
• Patients who have failed other therapies
• Peyronies disease
• Severe vasculogenic disease

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Choosing a Penile Prosthesis

• Considerations
• Medical condition
• Lifestyle
• Cost
• Insurance coverage
• As with all prescription products, complications
  are possible

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Malleable Prosthesis

• Easy for patient and partner to use
• Few mechanical parts
• Same-day surgery usually possible
• Least expensive type of prosthesis

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Two-Piece Inflatable Prosthesis

• Small inflation pump provides comfort and ease
• Fast and easy one-step deflation procedure
• Better conceal ability when flaccid than with
  malleable or self-contained devices

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Three-Piece Inflatable Prosthesis

• Most closely approximates the feel of a natural
  erection
• Cylinders expand in girth
• Some cylinders have the potential to expand in
  length
• When inflated, it feels more firm and more full
  than other prosthetic erections
• When deflated, it feels softer and more flaccid
  with better conceal ability than with other
  prosthetic devices

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Penile Prosthesis

• Advantages
• Low-morbidity
• Low-mortality surgery
• Low complication rates
• High success rates 5 malfunction rate at 5
  years
• High satisfaction rate 87
• High partner satisfaction rate

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Penile Prosthesis

• Advantages (cont.)
• Good rigidity
• Freedom from medications
• Outpatient/24HR surgery
• Resume sexual activity 4-6 weeks
• No loss of ability to ejaculate or achieve orgasm

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Penile Prosthesis

• Disadvantages
• Surgery
• Expensive
• Possible mechanical failure

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Penile ProsthesisInsurance Reimbursement

• Covered by most companies, including Medicare
• No co-payment for men with Medicare supplemental
  insurance

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When to Refer to a Urologist
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Refer Patients to a Urologist

• Patients who fail medical management
• Patients with Peyronies disease
• Patients with severe vasculogenic ED
• Patients on NTG who are not candidates for oral
  medications
• Patients requesting an implant

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Why Refer to a Urologist?

• Only specialty that is trained in andrology
  and/or management of ED
• Urologists offer a range of treatment options
• ED represents a significant aspect of many
  urologic practices
• Urology support staff is comfortable treating
  men and their partners who suffer from ED

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Summary

• ED is a common problem that affects millions of
  American men
• ED can be easily evaluated by the PCP
• ED can be treated with oral medications by the
  PCP
• Patients that do not respond to medical therapy
  should be referred to a Urologist
• Penile prosthesis is an effective means of
  treating ED

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Remember

• Primary care physician should consider early
  referral to Urologist if initial treatment is not
  successful
• No one needs to suffer the tragedy of the
  bedroom

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Any Questions?