HDR Peer Presentation Pennine Training Scheme Dr Lorna Clark, GPST 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)