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ASSESSMENT OF ERECTILE DYSFUNCTION

Dr Michael Gillman

• St Andrews Hospital –North St Specialist Suites

• Mater Hospital – 3rd Floor Mater Private Clinic

• Wesley Hospital Suite 5 Level 9 Evan Thomson Bld

• Cleveland- Shore Street West Medical Centre

Disclosure Slide

Advisor Lilly Australia Cialis and Axiron

Advisor Pfizer Australia Viagra / Caverject

Advisor Bayer Levitra

Advisor Andrology Australia Erectile Dysfunction Board

Advisor Menarini Priligy

Advisor Sanofi Adventis Xatral

Advisor CSL Flomaxtra

IMPOTENCE

Impotence is the inability to achieve or sustain an erection sufficient for the sexual needs of the man

or his partner

ERECTILE DIFFICULTIES

40% at age 40

50% at age 50

60% at age 60

70% at age 70

Do Men Really Care???

How many of your male patients book appointments to discuss erection problems ?

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Erectile Dysfunction History – Main Points

Duration of onset of problem.

Quality of all erections ( Spontaneous and sexual )

Relationship issues

Previous Treatments including Newspaper Commercial Clinics

Erectile Dysfunction History – Main Points

>70% have an organic component

Assume that most men have both Organic and Psychogenic

Psychogenic

Mainly Performance anxiety

Relationship Difficulties

Financial Difficulties

etc

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Diabetes Hypertension

The Deadly Quartet

Obesity Dyslipidemia

Why does ED occur earlier than cardiovascular disease?

Artery Diameter (mm) Critical events

Penile 1–2 Erectile

dysfunction

Coronary 3–4 Angina / MI

Carotid 5–7 TIA / Stroke

Adapted from Montorsi et al. Am J Cardiol 2005; 96: 19M–23M

The arterial size hypothesis

Examination

Examination

BP

Height Weight and waist circumference

Penile shaft for fibrosis

Testicles

Vascular system AAA, peripheral pulses

? Prostate with informed consent

Investigations

Renal and Liver Function Tests HDL/LDL

Testosterone ( LH and PRL if low ) TSH

Urine WTU ?PSA

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Testosterone and ED ??

• Low testosterone is an uncommon cause of ED

• However PDE 5 inhibitors do not work as well in the presence of low testosterone

• Free Androgen Index, Bioavailable Index and Free Testosterone are unreliable and generally not used

• “best of a bad bunch” is two morning sample serum testosterone levels

TREATMENT

Counselling

Viagra Cialis, Levitra, Uprima ( Not Yet Available )

Intracavernosal Injections ( Caverject and Combinations)

Trans-urethral Agents (MUSE) ( Not currently available)

Topiglans ( Not yet available )

Vacuum Devices

Penile implants

Low intensity Extracorporeal shockwave device

Testosterone

Vascular Surgery ( Selected Cases Only )

VACUUM DEVICES

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INTRACAVERNOSAL INJECTIONS

SELF INJECTION THERAPY (cont)

Side effects Scarring ?? No real evidence of this is injection

performed correctly

priapism

bruising

pain

Follow up at one month, then every six months as

appropriate

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PRIAPISM

The only real side-effect of injections

Prolonged erection not associated with sexual stimulation

After 24 hours may have irreversible cavernosal damage resulting in permanent erectile dysfunction

Must have action plan

Not usual with PDE5 inhibitors alone

INTRACAVERNOSAL IMPLANTS

Three – Piece Inflatable Penile Implant

Simple to use

Totally concealed within body

Acts and feels like a natural erection

Provides fullness and girth expansion

Softer and more flaccid when deflated

Disadvantages

Requires some manual dexterity

Possibility of malfunction

Possibility of leakage

Shockwave Therapy

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Extracorporeal Shockwave Therapy

Extracorporeal Shockwave Therapy

• Electrical energy is converted into acoustic shockwaves.

• When shockwaves come into contact with the endothelial wall there is the creation of cavitation forced, sheer stress and tissue radical formation.

• This has been shown to improve perfusion (1)

• Also shown to increase NO production (2) • 1. Aicher et al Shockwave Therapy Recruits Systematically Infused Endothelial Progenitor Cells Presented at AHA convention Nov 2005

• 1. Mariotto et al Extracorporeal shockwaves: from Lithotripsy to anti-inflammatory action by NO production 12(2):89-96 Mar 2005

Extracorporeal Shockwave Therapy

• Assumed that ECSWT may provide a rehabilitative or curative effect for ED

• Studies are underway at many centres and preliminary results show an improvement in IIEF of around 7 at 6 months

• ECSWT is applied at various points along the penile shaft and on the penile crura. Each treatment last around 20 mins and usual number of treatments is 12

• May have a role in men with vascular aetiology who are poor responders to PDE5 inhibitors

PDE5’s ARE DISCOVERED!!!!!!

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Oral Agents

Needs sexual stimulation to work

Allow time

On demand or daily dosing

Tailor management to individual couple Cost

Convenience

Efficacy

Side effects

The Role of PDE5 Inhibitors in Achieving and Maintaining Erection

cGMP-specific

protein kinase

Endothelial

cell

Guanylate

cyclase

GT

P

cGMP

K+

Ca2+

Decreased

Ca2+

Smooth

muscle

relaxation

& erection

Nitric

oxide

Smooth muscle cell

5'GMP PDE5

Cavernous

nerve

Sexual Stimulation

PDE5 Inhibitors

CHANCE OF A “CURE”????

CAVERNOSAL HYPOXIA

Aging effects on the corporal vasculature supply (hyperlipidaemia, hyperglycaemia etc.) cause hypoxic changes

Transforming Growth Factor TGF-B(1) is inhibited by prostaglandin

PGE(1&2) suppress collagen synthesis in human fibroblast cultures

CAVERNOSAL HYPOXIA (cont)

An imbalance between PGE and TGF-B(1) in the corpora due to hypoxia, may cause increased extracellular matrix deposition, inhibition of smooth muscle growth, and eventually fibrosis

PGE may have a role in the management of cavernosal fibrosis

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Main Points

Take a good history

Ask at risk patients about sexual function

Offer patients a range of options

Discuss pros and cons of each

Ensure they use product effectively

They do grow on trees!