Taking the measure of a Taking the measure of a manman

Dr. Simon TreissmanDr. Simon TreissmanOctober 10, 2007October 10, 2007

Taking the measure of a Taking the measure of a manman• Erectile dysfunctionErectile dysfunction

– Failure to Failure to attain attain an erection adequate an erection adequate for intromission.for intromission.

– Failure to Failure to maintainmaintain an erection for a an erection for a length of time adequate for satisfactory length of time adequate for satisfactory sexual relations.sexual relations.

Taking the measure of a Taking the measure of a manman

0

10

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30

40

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70

30's 40's 50's 60's 70's

SevereModerateMild

Age associated incidence of ED1. J Urol Vol 161(1) Jan 1999 pp 5 - 11

Taking the measure of a Taking the measure of a manman• How can you tell?How can you tell?

– International Index of Erectile function International Index of Erectile function (IIEF)(IIEF)

– 15 item questionaire15 item questionaire22 each with five each with five domains.domains.

– ““Test demonstrates sensitivity and Test demonstrates sensitivity and specificity for detecting treatment-specificity for detecting treatment-related changes in patients over time”.related changes in patients over time”.2. Urology 1997 Jun; 49(6): 822-30

Taking the measure if a Taking the measure if a manman• IIEF developed by RC Rosen in 1997IIEF developed by RC Rosen in 1997

– Evolved into Evolved into IIEF – 5IIEF – 5– Evolved into Evolved into Sexual Health Inventory for Sexual Health Inventory for

Men (SHIM)Men (SHIM)– Evolved into Evolved into SHIM-2 SHIM-2 33

3. Int J Impot Res 2005;17(4): 307 - 319

Taking the measure of a Taking the measure of a manman• Shim or IIEF – 5 handyShim or IIEF – 5 handy• Organic EDOrganic ED strongly associated with strongly associated with

certain diseasescertain diseases44::– Diabetes mellitusDiabetes mellitus– HypertensionHypertension– History of smokingHistory of smoking

4. J Diabetes Complications 2005 Jan – Feb; 19(1): 35 - 41

Taking the measure of a Taking the measure of a manman• Organic EDOrganic ED strongly associated with strongly associated with

certain drugs:certain drugs:– HydrochlorthiazideHydrochlorthiazide– Beta blockersBeta blockers– CimetidineCimetidine– SpironolactoneSpironolactone– Selective serotonin re-uptake inhibitors (SSRI’s)Selective serotonin re-uptake inhibitors (SSRI’s)– KetoconazoleKetoconazole

Taking the measure of a Taking the measure of a manman• Other Other common causescommon causes of ED: of ED:

– Prostate disordersProstate disorders•PSA, urinanalysisPSA, urinanalysis

– HyperprolactinemiaHyperprolactinemia•s. prolactins. prolactin

– HypogonadismHypogonadism•AM free testosteroneAM free testosterone•Bioavailable testosteroneBioavailable testosterone

Taking the measure of a Taking the measure of a manman

• RecapRecap::– Careful historyCareful history– Physical examPhysical exam– Lab assessmentLab assessment

Taking the measure of a Taking the measure of a manman• Treatment:Treatment:

– PDE 5’sPDE 5’s– Intra-cavernosal agentsIntra-cavernosal agents– Vacuum constriction deviceVacuum constriction device– Penile prosthesisPenile prosthesis

Taking the measure of a Taking the measure of a manman• Phosphodiesterase type 5 inhibitorsPhosphodiesterase type 5 inhibitors

– Original 5 phosphodiesterasesOriginal 5 phosphodiesterases identified identified in 1972 within rat brainin 1972 within rat brain55

– Now known to be Now known to be 11+ types / subtypes11+ types / subtypes– Sildenifil citrate Sildenifil citrate incidentally discovered incidentally discovered

in 1996 in 1996 66

5. Uznov and Brown6.6. Int J Impot Res Int J Impot Res 19961996 8 8 (2): 47 - 52(2): 47 - 52

Taking the measure of a Taking the measure of a manman

Sildenafil citrateSildenafil citrate TadalafilTadalafil LevitraLevitraRR

Titrate doseTitrate dose25, 50, 100 25, 50, 100 mgmg1 hour to 1 hour to onsetonset

Standard Standard dosedose20 mg20 mg½ hour½ hour

Standard Standard dosedose20 mg20 mg½ hour½ hour

Avoid food Avoid food and / or and / or alcoholalcohol

N / AN / A N / AN / A

Avoid a-Avoid a-blockers blockers NitratesNitrates

Just nitratesJust nitrates Just nitratesJust nitrates

Taking the measure of a Taking the measure of a manmanSildenafil citrateSildenafil citrate

½ life 3 – 4 ½ life 3 – 4 hourshours

TadalafilTadalafil

½ life 17.5 ½ life 17.5 hourshours

LevitraLevitraRR

½ life 4 – 5 hours½ life 4 – 5 hours

In VitroIn Vitro potencypotency

intermediateintermediateweakestweakest strongeststrongest