Adie Viljoen Lister Hospital Erectile dysfunction Adie Viljoen Lister Hospital

Erectile dysfunction and CVD

The Artery Hypothesis ED and Silent CAD Montorsi et al. (2005) Am.J.Cardiology 96 (Suppl): 19M-23M

How long does it take between ED and manifestation of CAD? ED symptoms developed BEFORE CAD in 67% of men. Average time to onset of CAD was 39 Months. VD = vessel disease In almost all pts, ED comes before CAD by an average of 2 up to 3 years European Heart Journal 2006 27, 2632 – 2639 (COBRA trial)

64 year old man Yearly DM review You ask him about ED

ED – Patient enquiry Only 10% men with ED seek advice Over 70% men with ED have not previously received any treatment Only 33% diabetic men with ED have discussed this with their GP

Why do Men Not Seek Help? 70% think their doctor will dismiss their concerns Sex is a Luxury Men do not connect ED with their underlying medical condition Shame & humiliation

Erectile dysfunction Erectile dysfunction defined as the inability to achieve and/or to maintain an erection for a sufficiently long period of time so as to permit satisfactory sexual intercourse. [Kloner. J. Am. Coll. Cardiol 2008:51:2051]

Erectile Dysfunction - Etiology Aetiology is due to complex interaction between psychological and physical factors

Associated disorders and causes of ED Smoking Hypothyroidism Diabetes Atherosclerosis Alcoholism ED Depression Neurological Disease Prostate Ca Hypertension Low Testosterone Renal Disease Hepatic Disease

ED & CVD ED is a marker of CVD Both conditions share numerous risk factors Vascular endothelium is the key

Vascular Endothelium Hypertension, IHD, ↑ cholesterol cause abnormality in vascular smooth muscle cells Cell dysfunction can precede atherosclerotic plaques Impaired endothelium-dependent vasodilatation via NO pathway

Risk factors for cardiovascular disease Metabolic syndrome Hypertension Increased fasting glucose and hyperinsulinaemia Dyslipidaemia (elevated triglycerides and reduced HDL-cholesterol) Truncal Obesity Microalbuminuria

Metabolic syndrome - hypogonadism Associated with hypogonadism and erectile dysfunction. [Traish et al. J. Androl. 2009:30;10-22]

Pathophysiology Inverse relationship between total testosterone and obesity due to: Increased aromatase activity in visceral adipose tissue leads to higher circulating levels of oestradiol which suppressed testosterone production by negative feedback.

ED and major adverse cardiac events Type 2 diabetic men ( 291 - follow-up for 4 years) with CHD. Those men who developed MACEs were about twice as likely to have ED than those men who did not develop MACEs1 Type 2 diabetic men (2,360) with no clinical evidence of CHD (27% had ED). Over a 4 year follow-up, the incidence of CHD was twice as great in men with ED as in those without ED.2 Gazzaruso et al. J.Am.Coll.Cardiol.2008:51;2040. Ma et al. J Am Coll Cardiol. 2008:51;2045

ED & metabolic syndrome Of 154 men with organic ED, 43% displayed metabolic syndrome (24% of general population), 79.2% displayed insulin resistance (general population 25%) and 90.9% displayed both insulin resistance and metabolic syndrome. [Bansal et al. J.Sex Med.2005;2:96]

Testosterone for all ? Testosterone therapy has significantly improved lipid profiles in men, reduced body fat percentage, increased lean muscle mass percentage, lowered blood pressure and decreased fasting blood glucose. Testosterone therapy may slow or halt the progression of metabolic syndrome, type 2 diabetes, CVD and erectile dysfunction.

ED = Warning for IHD!! CVD risk factors need to be identified A careful sexual history Physical examination Investigations Patient risk profile for CVD

Sexual History Onset, frequency, severity of ED Situational or partner-specific problems Early morning or nocturnal erections Perineal or back trauma Pelvic surgery

Examination Blood pressure Pulse (peripheral pulses) Sacral/perineal neurological examination Penile structure & testes Rectal (for tone & prostate)

Investigations Fasting glucose Testosterone (LH if hypogonadism) Lipids and cholesterol Thyroid Function Tests (PSA) (Prolactin - assessment of pituitary)

Sex & Exercise Sex is an exercise Heart rate reaches 120-150 /min BP reaches 150-180 systolic Duration is 5-15 min

Therapy Phosphodiesterase inhibitors Apomorphine Vacuum device Intraurethral therapy Intracavernosal injections Psychosexual counselling Penile prosthesis

Tadalafil Peak efficacy 2hrs post ingestion Not influenced by food Efficacy can last up to 36hrs

Sildenafil 1st PDE5 inhibitor >25 million men treated Effective 30-60 mins post ingestion Efficacy up to 4hrs Effective in all subgroups Dosages 25mg(56%), 50mg(77%), 100mg(84%)

Vardenafil Effective 30mins post ingestion Affected by fatty meal and alcohol 5mg(66%), 10mg(76%), 20mg(80%)

PDE5 Inhibitors-Safety Headache, flushing, dizziness, nasal congestion (5-10%) Visual disturbance (2%) Back pain, myalgia (6%)

PDE5 Inhibitors-Safety No ↑ MI rates No reduction in exercise tolerance or time to ischaemia in angina Totally contraindicated with nitrates Caution with α-blockers (except tamsulosin)

Which PDE-5 Inhibitor? Should be discussed with the patient. Individual assessment