Tom Havard 2013 Great Western Hospital GPST Teaching Erectile Dysfunction Tom Havard 2013 Great Western Hospital GPST Teaching

History Impotentia coeundi Chinese 2500BC: Yin-Yang, herbs, acupuncture. Egyptians 1600BC: Ground crocodile hearts, lotus flowers aphrodisiac (apomorphine) 300BC-1800s: Spanish Fly (cantharidin). Augustus Caesar, Henry IV, Marquis De Sade 1200s: Witchcraft 1873: First surgical treatment, blocking veins.

History 1918: Implanting monkey testicle, then cadavers, goats, boars, deer. Early 20th Century: Electric shock treatment. 1935 Holland: Discover Testosterone. 1960s: Penile implants 1970s: Penis pumps 1980s: Injections 1994: Viagra

Erectile Dysfunction Inability to initiate or maintain an erection to ejaculation. Erection: in tact parasympathetic reflex S2, S3. Ejaculation: in tact sympathetic L1 root.

Aetiology Blood Supply Hormones Nerves Psychological Hormones 70%

Aetiology Spinal cord or cauda equina Stroke PD MS Traumatic nerve/vascular damage: eg radical prostatectomy, pelvic # HTN, SSRIs, antihypertensives Smoking Leriche Syndrome Hypogonadism Peyronies Diabetes Depression, anxiety, stress Cycling

Epidemiology Affects 52% aged 40-70 10% complete ED 70% age >70yrs Those with ED twice as likely to have MI, 20% higher chance of admission with heart failure, 10% more likely to have stroke

History When, How… Early morning erections Anxieties about sexual matters Organic causes Diabetes, EtOH, Drugs, Relationships, conflicts, communication Depression

Investigations Bloods Glucose Testosterone, Prolactin TFTs Lipids Routine

Treatment Dependent on cause Psychological therapy to reduce anxiety, involving partner Lifestyle change shows improvement in sexual function in one third of obese men

Drugs PDE5 Inhibitors thus increasing cGMP and interaction with NO Sildenafil (Viagra) Tadalafil (Cialis) Vardenafil (Levitra) Also used for pulmonary HTN (Revatio), Altitude sickness, mixed with illicit drugs (beware amyl nitrate), cut flowers.

Eligible on NHS Diabetes MS Parkinsons Poliomyelitis Prostate Ca Prostatectomy incl TURP Radical pelvic surgery Renal failure treated by dialysis or transplant Severe pelvic injury Single gene neurological disease Spinal cord injury Spina bifida Receiving Tx 14/09/98 Impotence causing severe distress (after hospital assessment) One a week is appropriate, prescribers discretion to choose to give more

Contraindications Organic nitrates Hypotension <90/50. Careful use with alpha blockers Severe hepatic impairment Hereditary degenerative retinal disorders eg retinitis pigmentosa Recent stroke or MI Careful use with other P450 inhibitors eg cimetidine

Sublingual Apomorphine Dopamine agonist Not as effective as Sildenafil Only licensed oral drug not absolutely contraindicated for use with nitrates Positive response in 40-50% patients

Intracavernosal Injections Alprostadil, Prostaglandin E1 causes vasodilation Effective in up to 80% Few contraindications or interactions Requires training, manual dexterity, eyesight Pain on injection Also used to maintain patent ductus arteriosus

Transurethral Alprostadil Effective in 10mins, lasts 20-60mins Less effective than intracavernosal and slower acting, but less incidence of priapism

Vacuum Devices Plastic cylinder, vacuum created by hand or electric pump Constriction ring around base of penis Reported long term success in up to 60% of patients

Penile Prostheses Two types Malleable pair of rods with metal core Inflatable cylinders with internal pump and reservoir For patients that have failed to respond to other treatments or have developed fibrosis Risk of infection, erosion through the glans

Clinical Evidence Review Evidence of benefit: Alprostadil (both intracavernosal and transurethral), Apomorphine, Sildenafil, Tadalafil, Vardenafil Likely to be beneficial: Ginseng, prosthesis, psychosexual counselling, vacuum devices, yohimbe bark

Referral From Primary Care Urology Young men that have always had difficulty Hx of trauma (genitals, pelvis, spine) Clinical abnormality (micropenis, peyronies) Fail to respond to at least 2 max dose PDE5 Inhibitors Endocrinology Hypogonadism, abnormal testosterone, prolactin Cardiology Disease making sex or PDE5 use unsafe Psychologists

Summary Common – 52% aged 40-70 Multiple causes Take comprehensive history Investigate cardiovascular disease Consider psychological management Multiple treatments – First line Sildenafil Check if qualifies for NHS treatment and contraindications Refer as approprtiate