Erectile Dysfunction

HDR Peer Presentation Pennine Training Scheme

Dr Lorna Clark, GPST

What is Erectile Dysfunction

Synonym: Impotence Inability to attain and maintain an

erection sufficient for satisfactory sexual performance

Benign Significant impact on quality of life

Epidemiology

Incidence and prevalence is high worldwide

Effects up to 52% of men (40-70yrs) Steep age-related increase. Complete

impotence from 5% of 40yr olds to 15% of 70yr olds

Only 10-20% solely psychogenic

Risk factors

Note shared risk factors with CVD: Sedentary lifestyle Obesity Smoking Hypercholesterolaemia Metabolic syndrome Diabetes mellitus

Aetiology

Organic Hormonal Anatomical Drugs Psychogenic

Organic causes Vascular factors (CVD,

atherosclerosis, hypertension, diabetes, hyperlipidemia, smoking, trauma)

Central causes (Parkinson’s, stroke, MS, tumours, spinal disease/injury)

Peripheral causes (poly-/peripheral neuropathy, diabetes, alcoholism, uraemia, pelvic surgery

Hormonal causes

Hypogonadism Hyperprolactinaemia Thyroid disease Cushing’s disease

Anatomical causes

Peyronie’s disease Micropenis Penile anomalies (hypospadias etc)

Drugs Antihypertensives (beta blockers, diuretics) Antidepressants (tricyclic and SSRIs) Antipsychotics (phenothiazines,

risperidone) Anticonvulsants (phenytoin,

carbamazepine) Antihistamines H2 antagonists (cimetidine, ranitidine) Recreational drugs (inc tobacco and

alcohol)

Psychogenic Causes

General (disorders of intamacy, lack of arousability)

Situational (partner, performance, stress)

Psychiatric illness (Anxiety states, depression, psychosis, alcoholism)

Taking a history Take an understanding approach Sexual history – International Index of

Erectile Function questionnaire (IIEF) Current and Past sexual partners Current emotional state Erectile symptoms (onset and duration) Previous problems, advice and treatments Quality of erections (erotic and morning) Arousal, ejaculation and orgasm difficulties General medical/past medical history and

medications

History suggesting organic cause

Gradual onset Normal ejaculation Normal libido Medical risk factor Trauma/surgery/radiotherapy to

pelvis Current medication Lifestyle

History suggesting psychogenic cause

Sudden onset Early collapse of erection Self stimulated or waking erections Premature ejaculation or inability to

ejaculate Problems/change in relationship Major life event Psychological problems

Examination

Genitourinary examination (anatomical abnormalities, size of testes)

Pulses (femoral), BP Rectal examination (over 50yrs)

Investigation Bloods: Fasting glucose, lipids, U&Es, LFTs,

TSH, Early morning serum testosterone (plus FSH and LH if testosterone low)

Haemoglobinopathy screen (sickle cell) in afro-caribbean patients

Dipstick urinalysis Vascular studies (duplex ultrasound

cavernous arteries, arteriography, intracavenous vasoactive drug injection)

Neurological studies Specialist psychodiagnostic evaluation

Indications for referral

Endocrine abnormality Young patients with trauma Penile disorder/abnormality Complex cases Patient/partner request for specialist

tests/treatment

Management

Main goal: diagnose and treat underlying cause

Modify reversible causes (lifestyle, drugs). Men who initiated physical exercise and weightloss have upto 70% improvement (note: cycling more than 3 hours per week may cause dysfunction)

Treatment

Hormonal: testosterone failure – give testosterone

Post-traumatic arteriogenic: surgery Psychogenic: underlying problem, sex

therapy/counselling, phosphodiesterase type-5 inhibitors (sildenafil, tadalafil, vardenafil)

First-line treatment – oral therapy PDE-5 inhibitors improve relaxation of smooth muscle.

Contraindicated in patients receiving nitrates, recent stroke/MI, unstable angina

Sildenafil: well tolerated, efficacy reduced after fatty food, 50mg starting dose

Tadalafil: longer half-life, start at 10mg Vardenafil: more potent (but not clinically more

effective), useful in difficult to treat subgroups, effect reduced by fatty food.

Apomorphine hydrochloride: dopamine agonist, quick action, sublingual, not effected by foods

Treatment: Vacuum devices

External cylinder, pumping air out around penis and causing engorgement

Clinical success rate of 90% Work best: motivation, supportive

partner Adverse effects: pain, petechiae,

bruising, numbness

Second line treatments Intraurethral alprostadil (prostaglandin E1):

insert pellet urethral meatus, barrier contraception if partner pregnant, less effective than intracavernous injections, may cause penile pain

Intracavernosal alprostadil: injected, may cause pain and priapism (refer urgently to hospital for blood to be drained)

Third-line treatment

Penile prosthesis: semi-rigid, malleable or inflatable. Considered if impotence has organic cause and fail to respond to medical management

Topical agents: some vasoactive drugs come in topical gel form, may suffer local reaction and side-effects to partner if absorbed from vagina.

Prescription advice Medications only to be prescribed on NHS

if: diabetes, MS, Parkinson’s, poliomyelitis, prostate cancer, severe pelvic injury, spina bifida, spinal cord injury, receiving dialysis, history of radical pelvic surgery/prostatectomy/renal transplant, or receiving treatment before September 1998

Should also be available if dysfunction causing severe distress (significant disruption to normal social activities, interpersonal relationships and effecting mood, behaviour etc)