1. Adie Viljoen Lister Hospital
Erectile dysfunction
Adie Viljoen
Lister Hospital

2. Erectile dysfunction and CVD

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

4. 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 , 2632 – 2639 (COBRA trial)

5. 64 year old man
Yearly DM review
You ask him about ED

6. 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

7. 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

8. 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]

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

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

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

12. 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

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

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

16. 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.

18. ED and major adverse cardiac events
Type 2 diabetic men ( 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

19. 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]

20. 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.

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

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

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

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

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

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

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

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

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

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

31. 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)

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