Dr. Anmar Nassir, FRCS(C)

1

• Dr. Anmar Nassir, FRCS(C)
• Fellowship in Andrology (U of Ottawa)
• Fellowship in EndoUrology and Laparoscopy
  (McMaster Univ)
• Chairman, Department of Surgery Umm Al-Qura Univ
• Consultant Urology, King Faisal Specialist
  Hospital, Jeddah

2
Introduction

• Chronic renal failure causes a wide-ranging
  disturbance in men including sexual dysfunction.
• Historically, the prevalence of ED among renal
  failure patients varied 40 to 90
• Many recent studies reported similar prevalence
  (80-86) of sexual dysfunction in male patients
  while on HD.

Levy 1972, Abram 1975
Ali 2005, Rosas 2003, Neto 2002, Neya 2002,
Aeslan 2002, Rosas 2001, Rosas 2000
3

• This wide range perhaps because of different
  questionnaires used in addition to variable
  sample size
• Not all studies followed the accurate definition
  of ED as a persistent inability to achieve or
  maintain an erection sufficient to permit
  satisfactory sexual performance.

Ali 2005
4

• There is not enough data about the effect of
  modern dialysis therapy on sexual function.
• data is controversial about whether dialysis is
  helpful or harmful.

5

• Retrospectively, most studies documented no
  relationship between the duration of dialysis and
  severity of ED.
• One study demonstrated a significant correlation
  between the duration of dialysis and the presence
  of ED among HD patients.

Mehrsai 2006, Soykan 2005, Miyata 2005, Rosas
2003, Neto 2002, naya 2002, Cerqueira 2002,
Arslan 2002, Toorian 1997, Steele 1996, Rodger
1984
Ali 2005
6

• Prospectively, a study on 25 male patient given a
  sexual questionnaire twice in a period of 6 month
  to examine the ongoing effect of dialysis on ED
  and observed no significant improvement.
• Criticism
• This study only looked at a subset of a small
  number mixed of both genders.
• They did not assess the patients on entry to
  dialysis, but randomly at any time between 12192
  months of HD, with a mean of 67 /- 46.4 months.

Soycan 2005
7
In other words

• Many previous studies failed to adopt standard
  criteria to define impotence or to subcategorize
  sexual dysfunction.
• Absence of longitudinal studies planned to
  evaluate the impact of various renal failure
  therapies on ED.

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Objectives

• To determine the prevalence of sexual dysfunction
  in patients treated for renal failure.
• To identify the contributory risk factors.
• To determine the effect of standard renal failure
  treatment on sexual function, while on dialysis
  or post transplant.

9
Materials Methods

• Prospective study
• Started in 1998 with a follow up divided in
  stages.
• On admission to dialysis
• Every 10-12 months
• while on dialysis
• or post kidney transplantation.

10
Materials Methods

• The questionnaire used
• The international index of erectile function
  (IIEF)
• with its 5 domains,
• used to develop a semiquantitative baseline score
  useful in follow up.
• Other questions
• specially designed for our objectives were added.

11
Results

• Population
• 52 pts (at NS, Canada) fulfilled the criteria and
  returned 149 Questionnaire.
• 52 filled 1 questionnaire,
• 45 filled 2 questionnaires
• 34 filled 3 questionnaires
• 15 filled 4 questionnaires
• 4 filled 5 questionnaires
• Mean age was 58.5 /- 14.3 (SD)

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Results

• Renal Failure Therapy
• 25 HD 27 PD.
• During f/u 16 pts received a Kidney Transplant.
• F/U ranges from 0 to 48 months (average 20.5)
• 14 patients died during f/u.
• The rest had a mean f/u of 26 months.

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Erectile Function

• On entry to dialysis
• 82.7 have ED
• Only 17.3 were potent
• Severity

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Kidney Transplantation

• Some authors claimed that prevalence of ED in
  transplanted men was not significantly lower than
  in dialysis patients.
• Better designed studies, based on the IIEF-5
  scores of 64 patients
• 78.1 improved,
• 12.5 experienced no change
• 9.4 had a lower score.

Toorians 1997
Mehrsai 2006
15
Kidney Transplantation

• In a cross sectional study on 243 transplanted
  patients,
• ED was found in 54.9.
• Factors independently associated with ED were
• age, time on dialysis prior to transplant, and
  peripheral arteriopathy .
• Our data supported the beneficial effect of
  transplantation on sexual function with an
  advantage continued in a chronological prospect.
• Unmeasured variations in the previous studies
  probably resulted in the differences.

Rebollo 2003
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Evaluation

• H P
• IIEF-5
• Ix
• Lab CBC, Hb1ac, cholesterol, prolactin,
  Testosterone

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Treatment
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66.6 of ED pt are welling to have it treated.
Only 12 of ED pt had trt for it. Half of them
received it at gt30 months of f/u
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Significant observations

• Among the 5 domains of IIEF, sexual desire was
  relatively less affected.
• 35 patients with ED (66.6 ) were willing to be
  treated.
• Only 6 patients with ED (12) received treatment.

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• Although it is a major factor affecting quality
  of life in end stage renal disease (ESRD), SD in
  dialysis patients receives very limited attention
  by the medical team.
• Despite its importance, only 25 of patients
  discuss sexual function with their physicians

Diemont 2000
Soykan 2005
21
Treatment

• The reason for not seeking medical help is
  probably related to the high prevalence of
  psychological depression.
• This high prevalence is well documented.

Peng 2007, Kimmel 2000
22
Treatment why not ?

• There was significant correlation between the
  total score of IIEF and
• daily activities,
• social activities,
• social support ,
• quality of life.
• Some patients without sexual activity didnt
  perceive their deficiency as a problem and
  considered this situation inherent to the ageing
  process .

Martín-Díaz 2006
23
Treatment

• Among different modalities treating ED in ESRD
  patients, the simplest is using oral medication.
• Most studied were done on Sildenafil.

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Treatment by Sildenafil

• It is recommended to be used on days off
  dialysis.
• Next day after HD has better efficacy.
• Some authors showed that ED in two-thirds of HD
  patients can improve by sildenafil.

Yenicerioglu 2002
25
Treatment using Sildenafil
Yenicerioglu 2002
26
Treatment using Sildenafil
Yenicerioglu 2002
27
Treatment using Sildenafil
Yenicerioglu 2002

• ROC
• (receiver operating characteristic)

The ROC curve of the erectile function domain
score before treatment for predicting the outcome
of sildenafil treatment in patients with ESRD
(area under the curve, 0.790)
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Treatment using Sildenafil

• For the erectile function domain the ROC curve
• patients with a score of 17 seem to respond
  better to sildenafil treatment
• (with a sensitivity of 71 and a specificity of
  67).

Yenicerioglu 2002
29

• The response rate was 80 in those using HD when
  advised to take pills only on days with no
  dialysis
• Some authors reported transient hypotension after
  a 50-mg dose of sildenafil in patient on HD
• patients may remain relatively hypovolaemic for
  some time after dialysis, they recommended that
  sildenafil should be used on days with no
  dialysis.

Mohamed et al. 2002
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Treatment using Sildenafil

• Recommendation
• All patients were started on a 25-mg dose,
• Increased to 50 mg if there was no response after
  two trials.

Yenicerioglu 2002
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Double-blind, randomized, placebo-controlled study

• 50 mg sildenafil
• Inclusion
• patients with ED.
• Patients on HD for at least 6 mo
• With stable relationship with a female sexual
  partner

SEIBEL et al, 2002
32

• Exclusion
• Patients older than 70 yr
• penile anatomic abnormalities,
• cirrhosis,
• diabetes,
• angina,
• severe anemia,
• on nitrate treatment
• recent history of stroke or MI .

SEIBEL et al, 2002
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SEIBEL et al, 2002
34
SEIBEL et al, 2002
35
SEIBEL et al, 2002
36
SEIBEL et al, 2002
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Treatment

• When subdivided, diabetic patients responded less
  (37.5) compared to non diabetics (83.3).

Hyodo 2004
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(No Transcript)
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Side effects - Sildenafil

• At least one side effect was seen in 17/40
  patients (43)
• 5/40 (13) pts reported more than one side-effect
  
• 1 pt ? severe hypotension in the PD group.
• 12 pt (30) ? flushing.
• 7 pts (18) ? mild headache
• 1 pt ? blurred vision

Yenicerioglu 2002
40
Salvage Treatment

• 12 patients (8 Tx- 4 HD) who complained of ED
  with hypogonadism and cavernosal insufficiency.
• Before treatment
• all patients had severe ED with a poor IIEF score
  
• 11 had diminished libido.
• 11 pts had diminished testicular volume
• 6 had elevated FSH

Chatterjee 2004
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Salvage Treatment

• Received
• 250 mg IM/m testosterone cypionate and 50100 mg
  sildenafil orally once or twice / w
• 12 mo
• All patients had a good response

Chatterjee 2004
42
Chatterjee 2004
43
Sildenafil in Kidney Tx

• Even after renal transplant, those patients who
  still suffer from ED Sildenafil can be effective
  in 60.
• Multictr phase IV
• 50 pt post Tx w ED
• Sildenafil 50 mg then inc or dec
• X 3 mo

Castro 2001
Barrou 2003
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Sildenafil in Kidney Tx

• 65 ED patients with normal graft function for
  3-12 months after kidney Tx were involved in our
  study.
• Erectile dysfunction was diagnosed in all the
  patients by the IIEF.
• Among them,
• 10 patients were in light degree
• 32 patients in moderate degree,
• 23 patients in severe degree according to IIEF
  score.

Zhang et al, 2005
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Sildenafil in Kidney Tx

• In each patient, the IIEF score, were compared
  before and after taking sildenafil citrate at an
  initial dose of 50 mg every night.

Zhang et al, 2005
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Sildenafil in Kidney Tx

• Results
• 26 patients without ED before transplantation
  suffered ED after the operation,
• 32 patients with ED before transplantation
  noticed worsening.
• Taking sildenafil citrate was effective in 53
  patients (81.54).

Zhang et al, 2005
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Sildenafil in Kidney Tx
Zhang et al, 2005
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Sildenafil in Kidney Tx
Barrou 2003
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Sildenafil in Kidney Tx

• 66 of patients believed treatment had improved
  their erections.
• Patients reported improvements in their sexual
  life and partner relationships and a high level
  of satisfaction with treatment

Barrou 2003
50
Sildenafil in Kidney Tx

• 30/ 51 patients (58.8) presented with at least
  one SE during the study.
• Most of them were mild to moderate.

Barrou 2003
51
Sildenafil in Kidney Tx

• 5 patients (9.8) presented with at least one
  serious adverse event, which led to 3 patients
  being withdrawn from the study.
• 2 of the serious SE were considered possibly
  attributable to the study drug.
• 1 pt ? angina pectoris 1 day after the beginning
  of treatment
• 1 pt ? non-serious aggravated depression.

Barrou 2003
52
Sildenafil in Kidney Tx

• At the end of the study
• 27 patients (53) were taking a dose of 100
  mg/day,
• 1 patient (2) was taking a dose of 75 mg/day,
• 22 patients (43) were taking a dose of 50 mg/day
  
• one patient (2) was taking a dose of 25 mg/day.
• The average number of tablets taken per week
  between inclusion and the end of the study was
  3.3/-1.7 tablets.

Barrou 2003
53
Conclusions

• As life expectancy for these patients continues
  to improve and given the availability of oral
  medication for ED, physicians are urged to
  acknowledge the high prevalence of ED in ESRD and
  proactively question all patients with ESRD
  regarding their ED.
• This will improve the recognition of this
  condition among these patients, which can lead to
  adequate treatment and improved quality of life.

Neto 2002
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Conclusions

• Sexual dysfunction is very common among patients
  who have dialysis dependant renal failure.
• Sexual dysfunction is not altered by dialysis
  therapy.
• Renal Transplantation may improve erectile
  function.

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Conclusions

• Early evaluation of sexual function upon entry to
  dialysis is necessary.
• Provision of effective therapy to those with ED
  needs to be improved.