1. Andrology [ Erectile dysfunction ]
( Lecture )
Andrology [ Erectile dysfunction ]

2. Goals and Objectives Define erectile dysfunction (ED)
Discuss the most common causes of ED
Review a practical evaluation of men with ED
Review the treatment options
Provide suggestions for urologic referral

3. What is ED?
ED is the inability to achieve and maintain an erection adequate for intercourse to the mutual satisfaction of the man and his partner.
Remember, both partners in a relationship are affected.

4. Incidence 20-30 million American men suffer ED Age dependent
2% men age <40 years
25% men age 65
75% men >75 years
Not a necessary occurrence of the aging process

5. How Does an Erection Occur?
The brain controls all sexual functions, from perceiving arousal to initiating and controlling the psychological, hormonal, nerve, and blood flow changes that lead to an erection.
Hormones, including testosterone, control the male sex drive

6. How Does an Erection Occur? (cont.)
Nerve impulses relay signals of arousal and sensation to and from the penis
Arteries deliver extra blood to the penis that causes it to stiffen.
Veins then drain the blood out of the penis after intercourse.

7. Physical or Psychological Stimuli Results
Sacral parasympathetics (S2,3,4) stimulation to the penile nerves
Dilation of the penile arteries
Relaxation of the smooth muscle in the corporal bodies of the penis
Decrease venous outflow

8. An Erection Requires a Coordinated Interaction of Multiple Organ Systems
Psychological
Endocrine
Vascular
Neurologic

9. Mechanism of Smooth Muscle Relaxation
Release of Neurotransmitters-nitric oxide
Conversion of GTP to cGMP - erection
Breakdown of cGMP by PDE type 5 - detumesence

10. Cause of ED Psychogenic Causes: Anxiety Depression Fatigue Guilt
Stress
Marital Discord
Excessive alcohol consumption

11. Causes of ED Organic Causes Cardiovascular disease Diabetes mellitus
Surgery on colon, bladder, prostate
Neurologic causes (lumbar disc, MS, CVA)
Priapism
Hormonal deficiency

12. Causes of ED Risk Factors Massachusetts Male Aging Study¹
Treated heart disease 39%
Treated diabetes 28%
Treated hypertension 15%
¹Feldman Ha, J Urol 1994; 151:54-61

13. Causes of ED Other risk Factors ²
Diabetes 27% - 59%
Chronic renal failure 40%
Hepatic failure 25% - 70%
Multiple Sclerosis 71%
Severe depression 90%
Other (vascular disease, low HDL, high cholesterol)
²Benet et al. Urol Clinic North Am. 1995; 151:54-61

14. Causes of ED Hormone Deficiency End Organ Failure
Blockage of Blood Vessels
Venous Leak

15. Causes of ED Spinal cord injuries: 5% - 80%
Pelvic and urogenital surgery and radiation
Substance abuse
Alcohol: >600ml/wk
Smoking amplifies other risk factors
Medications may be responsible for ~25% of cases of ED
Bicycle riding

16. Causes of ED Medication: Most common cause of ED in men >50
Many men are polymedicated
Also have co-morbid conditions

17. Causes of ED Medications (cont.) Anti-hypertensive drugs All capable
Common: thiazides and beta blockers
Uncommon: calcium channel blockers, alpha-adrenergic blockers, and ACE inhibitors

18. Causes of ED Medications (cont.) CNS drugs:
Antidepressants, tricyclics, SSRIs
Tranquilizers
Sedatives
Analgesics
H1 and H2 receptor blockers

19. Causes of ED Medications (cont.) Anticholinergics
LHRH agonists (Lupron, Zolladex)
Alcohol
Tobacco
Drug abuse
Estrogens, Ketoconazole

20. A Practical Evaluation of Men with ED Basic evaluation
Medical History
Cardiovascular history
Endocrine history
Sexual history/questionnaire

21. A Practical Evaluation of Men with ED Basic evaluation (cont.)
Physical exam:
Focused neurovascular exam
Size of testis
DRE
Lab tests UA
Testosterone, CMP, Lipid panel
PSA in men >50 years

22. A Practical Evaluation of Men with ED Sexual History
Premature ejaculation
Retarded ejaculation
Painful intercourse
Anorgasmia
Decreased Libido
Dissatisfaction with sex life

23. A Practical Evaluation of Men with ED Sexual History (cont.)
Do you have any problems with intimacy with your partner?
Do you have early morning erections?
Do you have erections with self-stimulation?
Are you able to consistently obtain and maintain an erection sufficient for sexual intimacy?
Does it hurt to have an erection or intercourse?

24. A Practical Evaluation of Men with ED Sexual History (cont.)
Do you ejaculation sooner than you would like?
Does it take too long to reach an orgasm?
Do you fail to reach an orgasm?
Did your erection problems start suddenly or over time?

25. A Practical Evaluation of Men with ED ED Questionaire³
When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
How do you rate your confidence that you could get and keep an erection?
³The International Index of Erectile Function, Urol 1997;49:

26. A Practical Evaluation of Men with ED Questionaire (cont.)
During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
When you attempted sexual intercourse, how often was it satisfactory for you?

27. Psychogenic Impotence: Younger patient (<40)
A Practical Evaluation of Men with ED Differentiating Psychogenic from Organic ED
Psychogenic Impotence:
Younger patient (<40)
Preservation of morning erections and nocturnal erections
Achieve erection with masturbation
May be partner-specific
Often sudden onset

28. Gradual deterioration
A Practical Evaluation of Men with ED Differentiating Psychogenic from Organic ED
Organic ED:
Gradual deterioration
Decrease in morning erections and nocturnal erections
No erections with masturbation
No loss of libido
Presence of co-morbid conditions

29. A Practical Evaluation of Men with ED Physical Examination
Blood pressure
Examine penis (R/O Peyronie’s disease)
Determine size and consistency of testes
Digital rectal exam
Focused vascular exam/peripheral pulses
Focused neurologic exam

30. A Practical Evaluation of Men with ED Laboratory Tests
UA (glycosuria) – Fasting if elevated
PSA in men over 50
Testosterone (best to draw in A.M.)
Prolactin, Thyroid function, Lipid profile, Liver function, Creatinine

31. A Practical Evaluation of Men with ED Other Tests
NPT – Nocturnal Penile Tumescence Test
Penile doppler
Injection of vasoactive drugs
NEVA (Nocturnal Electobioimpedance Volumetric Assessment)

32. Treatment Options Goal directed therapy4
Find out what the patient wants
Try to tailor the treatment to the patients needs and wants
Etiology rarely affects treatment choice for the patient
4 Lue TF, World J. Urol 8:67,1990

33. Treatment Options
Nonpharmacologic
Non-invasive
Minimally invasive
Invasive
Counseling and/or sex therapy

34. Treatment Options
Oral medications - Viagra, Levitra, Cialis
Urethral suppositories (MUSE)
Injection therapy - Caverject, Trimix, Bimix
Vacuum constriction device
Surgery
Sex therapy

35. Counseling and/or Sex Therapy
Rule out depression
Try oral medication in patient with psychogenic impotence
Refer to sex therapist or psychiatrist for sever psychopathology

36. Nonpharmacologic Treatment Options
Lifestyle changes:
Reduce fat and cholesterol in diet
Decrease or limit alcohol consumption
Eliminate tobacco use and substance abuse
Weight loss if appropriate
Regular exercise

37. Ideal Medication for Treatment of ED
Effective
Available on demand
Free of toxicity and side effects
Easy to administer
Inexpensive

38. Medication (Viagra, Levitra, Cialis)
Mechanism of Action:
PDE inhibitor and increases the cGMP that promotes and sustains smooth muscle relaxation

39. Medication (PDE Inhibitors)
Indications:
Psychogenic ED
Mild vasculogenic ED
Neurogenic ED
Side effects from medication(s) patient is already taking

40. Medication (PDE Inhibitors)
Side effects:
Headache
Flushing
Dyspepsia
Nasal congestion
Visual disturbances
Priapism

41. Medication (PDE Inhibitors)
Contraindications:
Organic Nitrites:
Oral
Sublingual
Severe cardiac disease
Obtain stress testing

42. Medication (Yohimbine, Yocon, Erex, Yohimex)
Alpha 2 andrenoreceptor antagonist
Dose: 5.4 mg TID
Results: ~20% (same as placebo)
Side effects: increase blood pressure, tachycardia, anxiety

43. Medication Trazodone(Desyrel)
Anti-depressant associated with priapism
Mechanism of action nor fully understood
Nor FDA approved for ED
Side effects: drowsiness, dry mouth, sedation, priapism

44. Medication Apomorphine (Spontane)
Dopaminergic mechanism with hypothalamic activity
Sublingual administration
64% to 67% response rate with ED
Side effects: nausea, sweating, hypotension, yawning
Awaiting FDA approval

45. Medication Phentolamine (Vasomax)
Alpha-blocker
Relaxes smooth muscle tissue
40% efficacy in mild organic ED
Side effects: nasal congestion, tachycardia, dizziness, hypotension
Awaiting FDA approval

46. Medication Side effects
Discontinue tobacco, alcohol, and abusive drugs
Alter dosage of drugs with ED side effects
Change to another class of drugs

47. Transurethral Therapy Alprostadil - MUSE
Mechanism of Action: vasodilator
Administration: 125, 250, ug
Insert in the urethra
Erection occurs minutes later
Erection lasts minutes
Results: 10-65%
Side effects: Pain, bleeding, priapism (<3%)

48. Penile Injection Therapy Caverject, Edex, Tri/Bi-Mix
Mechanism of action: smooth muscle vasodilator
Administration: 10, 20, 40ug
Inject directly into corporeal bodies of the penis
Results: 70%-90%
Dropout rates: 25%-60%
Side effects: pain (36%), priapism (4%), fibrosis

49. Androgen Replacement Therapy
Indications: hypogonadism (<285ng/dl)
Avoid oral estrogens-increase LFTs
Injectable – 200mg testosterone (cypionate, enathate, propionate), q2-3 weeks
Transdermal
Patch
gel

50. Androgen Replacement Therapy
Avoid in patients with prostate or breast cancer
Slight increase risk of BPH
Monitor all patients with annual DRE and PSA

51. Vacuum Constriction Device
Mechanism of Action:
Penis placed in plastic tube
Air evacuated from the tube
Blood trapped in penis with constricting ring

52. Vacuum Constriction Device
Erection limited to 30 minutes
Results: 80%-90%
Contraindications: bleeding disorders, sickle cell disease, anticoagulation
Complications: coolness, petechiae, numbness, pain with ejaculation
High drop out rate

53. Vacuum Constriction Device
Was previously first-line treatment for ED
Seldom used now that oral therapy is available
Considered an alternative if patient fails oral therapy and does not want to proceed with surgery

54. Penile Prosthesis Indications:
Patients who have failed other therapies
Peyronie’s disease
Severe vasculogenic disease

55. Choosing a Penile Prosthesis
Considerations:
Medical condition
Lifestyle
Cost
Insurance coverage
As with all prescription products, complications are possible

56. Malleable Prosthesis Easy for patient and partner to use
Few mechanical parts
Same-day surgery usually possible
Least expensive type of prosthesis

57. Two-Piece Inflatable Prosthesis
Small inflation pump provides comfort and ease
Fast and easy one-step deflation procedure
Better conceal ability when flaccid than with malleable or self-contained devices

58. Three-Piece Inflatable Prosthesis
Most closely approximates the feel of a natural erection
Cylinders expand in girth
Some cylinders have the potential to expand in length
When inflated, it feels more firm and more full than other prosthetic erections
When deflated, it feels softer and more flaccid with better conceal ability than with other prosthetic devices

59. Penile Prosthesis Advantages: Low-morbidity Low-mortality surgery
Low complication rates
High success rates – 5% malfunction rate at 5 years
High satisfaction rate – 87%
High partner satisfaction rate

60. Penile Prosthesis Advantages (cont.) Good rigidity
Freedom from medications
Outpatient/24HR surgery
Resume sexual activity 4-6 weeks
No loss of ability to ejaculate or achieve orgasm

61. Penile Prosthesis Disadvantages: Surgery Expensive
Possible mechanical failure

62. Penile Prosthesis Insurance Reimbursement
Covered by most companies, including Medicare
No co-payment for men with Medicare supplemental insurance