1. Erectile Dysfunction Steven Lun The Townsville Hospital JCU
Mater Pimlico / Womens & Childrens
Ferring Australia Honary Board Member

2. Learning Objectives
On completion of this educational activity , participants should be better able to
Evaluate specific needs of patients & their expectations of ED treatment
Be able to take a sexual history
Implement ED treatment strategies

3. Erectile Dysfunction Common Problem
Inability to maintain an erection firm enough to have sexual intercourse
10 % Male population
30 million American men

4. Erectile Dysfunction Significantly associated with
Increased age
Diabetes
Cardivascular Disease
Hypertension
Depression
Smoking
Medications
Multifactorial etiology with physical and psychological factors

5. The Past
Pre 1980
Pyschogenic Problem

6. The Past 1960 ‘s 1970 ‘s 1980 ‘s - Understanding early surgery Pumps
implants
1980 ‘s - Understanding
Injections 1983 Brindley

7. Role of NO & cGMP NO is released cGMP formed
Flaccidity
Guanylate Cyclase
Erection
Nitric Oxide
NO is released cGMP formed
Lower intracellular calcium
Penile smooth muscle relaxation
And increased blood flow leads to
Erection
PDE5 terminates NO/cGMP signaling
leading to flaccidity
GTP
5’-GMP
PDE5
cGMP

8. NO Receptor Diseases with abnormal NO Production Hypertension Obesity
Dyslipidemias
Diabetes I and II
Heart Failure
Atherosclerosis
Aging
Cigarette smoking

9. 1980-90’s Andrology IIEF International Index Erectile function
Sep Shim EHS Sear Pairs Edits QEQ Sex Q
NTP tests
Dynamic cavernosography
Hormonal Testing

10. 1990’s Vascular Agents Phosphodiesterase Inhibitors Prostaglandin
Sildenafil Viagra
Vardenifil Levitra
Tadenafil Cialis
Prostaglandin
Alprostadil
Caverjet

11. The Present Patients are in the drivers seat Trial PDE5 inhibitor
Intracavernosal therapy
Referral

12. The Future Newer agents Avanafil Post Radical Prostatectomy Diabetes
Acts 15 min
No effect with food

13. Urologists
Assess
Investigate
Appropriate option

14. Vacuum Device
Externally applied device mechanically effects penile blood engorgement
Cylinder/pump placed over penis creates closed chamber; pump creates vacuum, drawing blood into corpora cavernosa
Constrictive elastic ring then placed at base of penis to restrict flow of suctioned blood

15. Vacuum Device Some Advantages Some Disadvantages Non-invasive
Drug free
Cost effective
Some Disadvantages
Cumbersome
Unnatural erection
Erection is not warm to the touch
Bruising/burst blood vessels
Penile pain/discomfort
Numbness
Delayed ejaculation

16. Intracorporeal Injection Therapy
A small needle is used to inject medication directly into the penis. The medication allows blood to flow into the penis creating an erection.
Some Advantages
Effective erection
On-set of erection within 5 to 20 minutes

17. Intracorporeal Injection Therapy
Some Disadvantages
Risk of erection lasting 4 hours or more (priapism)
Fear of sticking needle in penis
Possible bleeding at injection site
Requires training
Possible pain at injection site
Cavernosal fibrosis
Poor long-term tolerability

18. Penile Implants
An Option For men who have tried other option without success
40 year history
High patient and partner satisfaction

19. Satisfaction Rates
Overall Patient Satisfaction with ED Treatment

20. Types Penile Prosthesis
One-Piece Non-Inflatable
Two-Piece Inflatable
Three-Piece Inflatable

21. Three Piece Prosthesis
Some Advantages
Totally concealed in body
Device is inflated to provide rigidity and deflated for concealment
Erection longevity is controllable
When deflated, the cylinders are soft and flaccid
Expands in girth (all AMS 700® cylinders) and length (AMS 700 LGX ® and Ultrex ® cylinders)

22. Possible Risks
Will make latent natural or spontaneous erections as well as other interventional treatment options impossible
If an infection occurs, the prosthesis may have to be removed
May cause the penis to become shorter, curved or scarred
There may be mechanical failures of the prosthesis
Urogenital pain (typically associated with healing process )

23. How Well Are We Doing
Not that great

25. Physician trends Prescriptions for ED Constant 2007-10
Primary Care Physicians prescribe majority Medicines followed by Urologists
Urologists Start twice as many new prescriptions

26. What Are Patients Looking For
PDE5 I – 50 % dissatisfied
Cost
Product performance
Spontaneity

27. What Are Patients Looking For
Preferences depend on
Age
Duration ED
Prior Rx Experience
Sexual Dynamics vs
Dynamics and frequency sexual relationships
Side effects
Duration of Action
Consistency of response
Partner satisfaction

28. An Uncomfortable Situation

29. Has Your Doctor Asked Whether You Have Sexual Difficulties?

30. Barriers to Discussing ED
Physician
Discomfort
Lack of Knowledge
Personal Bias
Time constraints
Patient
Embarrassment
Shame
Ignorance re normal
Cultural beliefs
Religious beliefs

31. Impact Of Physician Questioning On Patient Report Of Sexual Complaints
Spontaneous reporting ~ 14%
Reporting after Direct Questioning ~ 55%

32. Why Take A Sexual History
Sexual problems may be the harbinger of underlying disease
Sexual health is an Unalienable right of every patient
Has the potential to improve patient – physician relationship
Sexual problems are eminently treatable
Important part of setting realistic expectations

33. Principles for Sexual History Taking
Patients prefer clinician to Initiate
Adjust language to the individual patient
Assure confidentiality
Empathetic & normalizing statements
Demonstrate lack of embarrassment
Cultural Sensitivity
Avoid judgement statements & assumptions
Avoid ageism
Ask the partner if present

34. Sexual Problem Assessment
Phases Affected – Tumescence Ejaculation Orgasm
Lifelong vs acquired ( timeline )
Generalized vs situational
Sudden vs gradual
Distress = Bother
Partner based vs self stimulation
Rigidity
Sustaining capability
Nocturnal erections

35. Screening for Sexual Dysfunction
Open ended Style questions
“Men with diabetes often suffer from ED”
“Are you having any problems with ? “
“Tell me more “
“What do you mean by that “

36. Take Home Messages Sexual history taking is important
Sexual history is not an innate skill
Training in this area needs improvement
Basic Principles are worth following
Practice and comfort development are essential
Appropriately taken history can impact upon
Patient diagnosis
Patient decision making
Patient satisfaction

37. Case 1 52 Yr old male executive Enquiring re Vasectomy Complains of ED
BMI 26
Medications Atenolol Nexium
What Questions would you ask and would you investigate?

38. Case 2 48 Yr Aircraft maintenance Fitter Complains Impotence 5 years
F Reseal Deseal exposure
Complains Impotence 5 years
Unable to initiate Tumesence
Has Tried Viagra – no benefit
Parathesia of feet
What questions and investigations would you ask for

39. Case 3 62 Yr old male 75 kg Ex Medical Rep wishing for Cure of his ED
40 year smoker
PSA 8 CaP Gleason 7 – Radical Prostatectomy 2 yr previous
No Medications
Cialis of no benefit
What Questions would you ask
Any Investigations you would do ?

40. Case 4 48 Yr Salesman c/o Impotence 5 Years
Can initiate Tumesence but soft and premature detumescence
Has tried viagra ,Mens Clinic to no avail
Wife accusing him of playing around threatening to leave
No medications
What Questions and Investigations would you ask ?