dr hilgard ackermann fc (urol)academic.sun.ac.za/stellmed/coursematerial/annual gp conference...

GP Refresher Course – 2017

Dr Hilgard Ackermann FC (Urol)

Premature Ejaculation

Erectile Dysfunction

Penile Curvature

Ejaculatory Disorders

New consensus statement Ejaculation that always or nearly always occurs prior

to or within about 1 minute of vaginal penetration (lifelong PE) or a clinically significant and bothersome reduction in latency time, often to about 3 minutes or less (acquired PE).

The inability to delay ejaculation on all or nearly all vaginal penetrations.

Negative personal consequences, such as distress, bother, frustration, and/or the avoidance of sexual intimacy.

ISSM Consensus Statement 2016

Different types of PE?

Life-long

Acquired

▪ Natural variable vs Subjective

▪ PE-like ED

Etiology largely unknown

Theories exists: anxiety, penile hypersensitivity, and 5-HT receptor dysfunction

Important from the history▪ Onset of problem (Classify)

▪ Time to ejaculation

▪ Perceived control

▪ Distress and interpersonal difficulty related to the ejaculatory dysfunction

▪ Subtype ? Premature Ejaculation Diagnostic Tool (PEDT) ▪ No role in clinical context

Important from the physical examination▪ Anatomical deformities, urethritis, prostatitis

Dapoxetine 30mg / 60mg (Priligy©)

FDA approved: On-demand usage

Tmax 1.3hr; ½ life 24 hrs.

2.5- and 3.0-fold increases IELT

Safe to use with PDE5-Inhibitors (risk syncope)

▪ Tadalafil combination tablet = Tadapox (FDA)

EAU 2017

Anejaculation▪ Involves complete absence of antegrade or retrograde ejaculation

Retrograde ejaculationTtotal, or sometimes partial, absence of antegrade ejaculation as a result of semen passing backwards through the bladder neck into the bladder.

Anorgasmia▪ Inability to reach orgasm and can give rise to anejaculation. It is a

primary condition and its cause is usually psychological.

Asthenic / delayed ejaculation

Pitfalls in management

Beware of SSRI withdrawal syndrome

Careful prescription of SSRI in young men < 18yr or with MDE / Bipolar

Impact of condom usage on marital partner

Topical anaesthetic agents reduces effect on both partners.

The persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance.

There is increasing evidence that ED can be an early manifestation of coronary artery and peripheral vascular disease.

HormonalPelvic Trauma

PSA TT +- LH

HbA1C; Creat; Lipogram

EAU 2017

SildenafilVardenafilTadalafil*Avanafil

CaverjectBimixTrimixQuadmix

1st 2nd

All PDE5Is are contraindicated in:▪ Patients who have suffered from a myocardial

infarction, stroke, or life-threatening arrhythmia within the last 6 months

▪ Patients with resting hypotension (blood pressure < 90/50 mmHg) or hypertension (blood pressure > 170/100 mmHg)

▪ Patients with unstable angina, angina with sexual intercourse

▪ Congestive heart failure categorised as New York Heart Association Class IV.

PDE5Is

Drug-interactions▪ Nitrates (all forms) – contra-indicated

▪ Anti-hypertensives – safe (take care with Doxasozin)

Dosage adjusments▪ Needs higher dose: Phenytoin, Carbamazepine, Phenobarbitol

▪ Needs lower dose: Ketokonazole, Itraconazole, Clazithromycin.

Conditions: ▪ Renal failure, hepatic failure ?

Intracavernosal injections

Alprostadil (Caverject®)

▪ 5-40 mcg

▪ Test dose first

▪ Physician instructed

▪ Side-effects: Pain, hematoma, fibrosis, priapism

Stronger alternatives: BiMix, TriMix, QuadMix

EAU 2017

3rd MalleableInflatable

Correct dosage?Taken at least 6?Grey product?Waiting too long?No sexual stimuli?

Malleable Inflatable penile prosthesisR19,000 R80,000

Important to note

Different types: Malleable vs Inflatable Penile Prosthesis (IPP)

Recognition of complications

▪ Inguinal hernia formation

▪ Erosion / extrusion of corporal cylinder

▪ Mechanical failure signs

▪ SST (supersonic transporter) or sigmoid deformity

Pitfalls in management▪ Inadequate patient counselling

▪ Drug interactions / dosage adjustments

▪ Not evaluating the cardiovascular risk status

▪ When to refer to a Urologist?

Congenital

Rare (< 1%)

Disproportionate development of the tunica albuginea of the corporal bodies, usually ventral.

Referral to Urologist

Acquired

Peyronie’s Disease

0.4-9%, age 55-60, diabetics with ED

Important from the history Degree of Erectile Dysfunction (Score: IIEF score)

Ability to penetrate / successful sexual intercourse

Duration of onset (< or > 12m)

Degree of curvature (<30°, 30°-60°, >60°)

Presence of pain?

History of prior treatment

Important from the physical

General

▪ Examine hands – Duputreyn’s contractures [Ortho]

▪ Examine foot soles – Lederhose disease [Ortho; Podiatrist]

▪ Examine ears – Tympanosclerosis [ENT prn]

Penis

▪ Plaque (ventral / dorsal / lateral / size), presence of pain

▪ Degree of curvature –# Selfie by patient

Rationale behind medical treatment

Acute (painful) phase, interact with presence of growth factors

Natural process of plaque

▪ 48% stabilize; 18 % regress ; 25% worsen

Medical treatment options

▪ Oral, intralesional and external options

▪ Xiaflex: Newly approved by FDA.

Rationale behind surgical options

Reduce degree of penile curvature, chronic phase

Surgical options

▪ Degree of curvature important – 60 degrees

▪ “Penile lengthening” vs “shortening” options

▪ Risk of de novo erectile dysfunction

▪ Penile prosthesis if significant ED and curvature exists

NESBIT

GRAFT

Pitfalls in management

Investigating penile pain – examine closely for plaques.

Associated pathology.

Complications of penile prosthesis

Side effects of medical management.

Timely referral to Urologist