erectile dysfunction
TRANSCRIPT
Erectile dysfunction –a growing problem
Dr Thomas Fox
Endocrine SpR
Royal Cornwall Hospital, Truro
Erectile Dysfunction (ED)
Definition Epidemiology Aetiology Clinical features
History Examination
Investigation Treatment
Definition
The consistent inability to obtain and maintain penile erection sufficient to complete satisfactory sexual performance
Epidemiology
Estimated to affect 152m men worldwide Non-diabetic men 0.1-18.4% prevalence In a study of 541 diabetic males
35% in diabetic men 5.7% in 20-24 year olds 52.4% in 55-59 years olds
ED is a growing problem Massachusetts Male Aging Study estimate an
11% world increase by 2015
Aetiology
Vascular Neurological Endocrine Psychological Pharmacological Penile tissue abnormalities Others
Vascular
Arterial insufficiency Endothelial dysfunction (up to 95%) Discrete lesions
Venous leakage Failure of venule constriction
Neurological
Damage to autonomic nervous system Predominant parasympathetic damage
Endocrine
Hypogonadism Most commonly primary testosterone deficiency Secondary hypogonadism
Hypothyroidism Hyperprolactinaemia
Other causes of ED
Penile Balinitis Phymosis Penile finrosis Tumours Trauma
Pharmacoloical
Clinical features
History Examination
History
Patient’s description of the problem Patient’s and partners expectations Duration Speed of onset Intermittent/progressive? History of sexual partners Nocturnal erections? Libido
PMH Glycaemic control Vascular/neurological disease Urological PSH and trauma
DH Anti-hypertensives Androgen antagonists Sedatives Drugs that cause hyperprolactinaemia
(phenolthiazides) Alcohol
Psychological assessment
Examination
General Vascular Neurological Genitalia DRE
Investigation
Diabetic/vascular Endocrine
9am Testosterone Thyroid function tests Pituitary hormones (LH,FSH,PRL)
Imaging
Management
Multidisciplinary approach Involvement of partner Couples expectations and desires
Oral therapies
Phosphodiesterase V inhibitors Sildenafl (Viagra) 4hr Tadalafil (Cialis) 17hrs Vardenafil (Levita) 4 hrs
Side effects flushing, headache and GI disturbance
Contraindications - nitrates
Efficacy of PDE-V inhibitors
Hundreds of studies internauinally Improved erections and increased successful
episodes of sexual intercourse vs placebo (15 RCTs)
Levinson et al 1998
254 males over 18 with clinical diagnosis of ED for >6 months
Randomised double blind placebo controlled trial
Primary end-point Index of Erectile Function (IEF)
Variable dose 25mg-100mg adjusted by the patients
IEF Q3 ability to obtain erection
IEF Q4 ability to maintain erection p<0.0001
IEF7 satisfaction with therapy
Improved erections at 12 weeks
p<0.0001
% successful sexual attempts in last 4 weeks p<0.0001
PDE V inhibitor prescribing
Following conditions DM PD, MS, polyiomyelitis Pinal cord injuries, spina bifida Radical prostatectomy
Trial of 8 doses with dose titration before classifying as failure of treatment
Once correct dose achieved then can prescribe 1 tablet per week
Vacuum devices Can improve erection Messy and user dependent Satisfaction varies 35-80%
Intracavernosal injections
Intracavernosal injections with prostaglandins Alprostadil (prostaglandin E1)
One large RCT found increased rate of satisfactory erections when alprostadil injected compared to placebo
Side effects – pain, priapism
Testosterone replacement
Improves erectile function and libido Preparations
Topical (testim gel) Im testosterone Long-acting depots
Testosterone replacement improving diabetes? Kapoor et al 2006 Small double-blind placebo controlled crossover trial (n=24) T II DM with testosterone deficiency (10 on insulin therapy) 3 months treatment with testosterone (200mg im 2-
weekly)replacement and 3 months with placebo (1 month washout)
Endpoints – fasting glucose, HbA1C and HOMA in non-insulin treated subjects (homeostatic model index)
Secondary endpoints waist circumference, BP and lipids
Results HbA1C reduced by 0.37% (p=0.03) Fasting glucose reduced by
1.58mmol/L(p=0.03) HOMA index reduced 1.73 (p=0.02) Waist circumference reduced 1.73cm (p=0.03) Total cholesterol reduced 0.4mmol/L (p=0.03) No effect on BP
Conclusions Testosterone replacement can improve T II diabetic
control
Intraurethral alprostadil Effective but requires sufficient training
required
Penile implant
•Inflatable
•Malleable
Psychosexual counselling
Talking therapies for men and couples
Summary
ED Common Marker for other forms of neurovascular
complications in diabetes Psychologically damaging Treatable Treat associated hormonal deficiencies
References
Efficacy and safety of sildenafil citrate (Viagra®) for the treatment of erectile dysfunction in men in Egypt and South Africa International Journal of Impotence Research (2003) 15, Suppl 1, S25–S29.Levinson et al
Testosterone replacement therapy improves insulin resistance, glycaemic control, visceral adiposity and hypercholesterolaemia in hypogonadal men with Type II Diabetes
Kapoor et al European Journal of Endocrinology 2006
Diabetes Chronic conplication
Wiley press, Shaw et al
The role of testosterone in erectile dysfunction
Gooren et al