restoring erectile function · penis –plaque(s) location, size, stretched length, measuring...
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Restoring Erectile FunctionChris Deibert MD MPHAssistant Professor of Urology – UNMCMen’s Health Program – Nebraska Medicine
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All materials are included with the permission of the authors. The opinions expressed are those of the authors and are not to be construed as those of the University of Nebraska Medical Center, Center for Continuing Education, Nebraska Medicine, or American Nurses Credentialing Center’s Commission on Accreditation.
The faculty and Planning Committee members listed below, have no conflicts of interest to disclose.Christopher Deibert, MD, MPH; Brenda Ram, CMP, CHCP; Jeannie Trichel, MHRM; and Jackie Siebels, BSN, RN-BC
Series of ActivitiesAvailable Online
UNMC-CCE offers topics of interest to medical professionals that are available online for CME credit at:
www.unmc.edu/cce/outreach
OutlineBackgroundDefining Sexual DysfunctionEvaluationTreatment options
1) Recognize that many sexual dysfunction symptoms predict early cardiovascular disease
2) Identify other metabolic diseases that can mimic sexual dysfunction
Why me to discuss this today?- Director of Nebraska Medicine Men’s Health Clinic- Fellowship in Male Fertility, Sexual Dysfunction, Andrology
Chris Deibert has no funding disclosures related to this discussion.
Erectile DysfunctionDefinition: inability to achieve erection sufficient for penetration or unable to sustain the erection
Frequency of ED increases with age
MMHS 1994
40%
30%
15%
6%
5%3% 1%
Vascular
Diabetes
Vascular
Diabetes
Medication
Pelvic Surgery, Radiationor TraumaNeurological Causes
Endocrine Problems
Other
Medication
Erectile Dysfunction Causes
Normal Erections
Nitrous Oxide and Erections
Mechanism of creating erectionsNO is ubiquitous in bodyLeads to muscle relaxation and increased penile blood flowNO means more substrate for enzymes leading to erections
Symptoms: Things Guys Tell Me
• Change in quality/strength of erections• Difficulty with penetration• Gradual onset• NEW onset curvature to the penis• Sometimes painful with erections
• Most men indicate “emotional distress”, stress on relationships and poor self image
• Partners also affected
Symptoms: Things I Ask• We see this all the time in our office• What is the quality of his erections?
Erection Hardness Score (EHS)• Is there curvature to the penis? How much, when did this begin? Is pain present or a lesion/plaque?• Does this interfere with sexual activity?• How bothered is this man? • Is his partner?
Symptoms: Things I AskSexual Health Inventory for Men1) How do you rate your confidence that you could get and
keep an erection?2) How often were your erections hard enough for
penetration?3) How often were you able to maintain the erection after
penetration with your partner?4) How difficult was it to maintain your erection to the
completion of intercourse?5) How often was intercourse satisfactory to you?
Physical Examination
General physical examRectal exam – should this man be screened for prostate cancer? (age 55-69, family history) Colon cancer (age>50, family history)Penis – plaque(s) location, size, stretched length, measuring degree of curvature with erect penisHands – for evidence of contractures of fingers
May do an office ultrasound of the erect penis to examine erection quality, look for any plaque or curvature prior to treatment
Erectile DysfunctionTreatment
Lifestyle Modification- Smoking cessation, cut back or quit- Goal of ideal body weight- Regular exercise- Tight diabetes/sugar control (causes 30% of ED)- Good blood pressure management (causes 40% of ED)- Counseling
- The goal with many of these is to increase nitrous oxide availability and delivery to the penile tissues
Erectile DysfunctionTreatment
Risk Factors Shared• Smoking• Diabetes type 2• Dyslipidemia• Hypertension• Obesity• Increasing age• Sedentary lifestyle
Not really treating ED but reducing Cardiovascular disease risk
ED without CVD confers OR 1.25-1.48 in the next 5 years
Araujo; Princeton IIIADVANCEJY Dong 2011
Smoking and EDSmoke causes endothelial dysfunction and dysregulation of the Nitrous Oxide pathway
It doubles the likelihood of EDMixed data on dose-dependent relationship on erections
Smoking Cessation
Even 24 hours of smoking cessation improves rigidityImprovement seen when using nicotine patch
Massachusetts Male Aging Study showed that cessation at least stops progression of ED
No data on vaping yet
Guay AT Endocr Pract 1998Biebel MG J Sex Med 2016MMAS
Alcohol
Mild Alcohol1-2 drinks daily reduces ED risk OR 0.79
Excessive AlcoholSuppresses NO and leads to structural changes in penis and ED
Blood Pressure35-68% of men with hypertension have ED.This is a complex relationship
Khatana A 2008Burchardt M 2000Baumhakel M 2011
- beta blockers-/+ Calcium channel blockers-/+ ACE inhibitors-/+ Angiotensin II blockers
Glycemic Control
For diabetes, decreasing HbA1c signifies better glycemic control. Erection quality improves substantially for each point of A1c improvement
Romeo JH 2000
Obesity
Obesity inflammatory cytokines and insulin resistanceThis increases ROS and decreases vascular NO
The effect of obesity is independent of DM, cholesterol, hypertension
Esposito K JAMA 2004
Weight LossContinuous effect: the more weight loss, the better the erections
Esposito K JAMA 2004
Weight loss/Exercise None
Exercise:The Greatest of These
Sedentary lifestyle increases ED risk 2-10 fold
Mechanism of improvement:Increases NO, improves glucose sensitivity
Daily exercise produces 4x the NO compared to just 1 intense workout
Selvin E Am J Med 2007Haram PM 2006
When Lifestyle Change is Not Enough: ED Treatment
Oral Therapies: Phosphodiesterase inhibitors
- Viagra- Levitra- Cialis- Stendra
- 35-75% are able to have intercourse on therapy
Erectile DysfunctionTreatment
Drug Sildenafil(Viagra)
Vardenafil(Levitra)
Tadalafil(Cialis)
Peak effect 0.5-1 hr 0.7-0.9 hr 2 hr
Alcohol or fatty meal decreases absorption
Yes Yes Yes
Duration of effect
4 hr 4 hr 24-36 hr
Side effects Visual changes Back and limb muscle pain
Side effects (all) •Decreased blood pressure, headache, flushing (12%-16%)•Nasal congestion (2%-4%)•Gastric reflux, nausea (5%-7%)•Priapism (very rare)
FDA-Approved Phosphodiesterase Inhibitors for Erectile Dysfunction
Erectile DysfunctionTreatmentVacuum Erection Devices- 80% success
SpecializedUrology
Erectile DysfunctionTreatmentUrethral Suppository
Injectable therapies- Self injection at base of penis- Like an insulin injection for Diabetics- 85% success
Zotarolimus-Eluting Peripheral Stents for the Treatment of Erectile Dysfunction in Subjects With Suboptimal
Response to Phosphodiesterase-5Inhibitors
Erectile DysfunctionTreatment
Surgery: Penile Prosthesis- Final option- Completely inside body- Consistent erection quality- Patient and partner satisfaction
are >90%
Erectile DysfunctionTreatment
Surgery: Penile Prosthesis- Risks:
- Infection- Erosion - Mechanical failure (95%
work at 7 years)
- Consistent erection quality
Treatment Plan
• Try to determine cause of the Erectile Dysfunction• Improve lifestyle first: weight, blood pressure,
diabetes, smoking• If vascular, often trial an oral medication first• Try a different oral medication• Consider vacuum or injection therapy• If none of the above works, consider prosthesis
surgery
Conclusion
Erectile Dysfunction causes are many
Lifestyle modification can improve erectile function and those same changes improve other health parameters as well
The ACTIVITY CODE is:40468
For the webinar you will need this ACTIVITY CODE so you can complete your evaluation form and receive your CME Certificate.Instructions are also on the website at:
www.unmc.edu/cce/outreach
Men’s Health Program402-559-4292