1. HDR Peer Presentation Pennine Training Scheme Dr Lorna Clark, GPST
Erectile Dysfunction
HDR Peer Presentation
Pennine Training Scheme
Dr Lorna Clark, GPST

2. 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

3. 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

4. Risk factors Note shared risk factors with CVD: Sedentary lifestyle
Obesity
Smoking
Hypercholesterolaemia
Metabolic syndrome
Diabetes mellitus

5. Aetiology
Organic
Hormonal
Anatomical
Drugs
Psychogenic

6. 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

7. Hormonal causes Hypogonadism Hyperprolactinaemia Thyroid disease
Cushing’s disease

8. Anatomical causes Peyronie’s disease Micropenis
Penile anomalies (hypospadias etc)

9. 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)

10. Psychogenic Causes
General (disorders of intamacy, lack of arousability)
Situational (partner, performance, stress)
Psychiatric illness (Anxiety states, depression, psychosis, alcoholism)

11. 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

12. History suggesting organic cause
Gradual onset
Normal ejaculation
Normal libido
Medical risk factor
Trauma/surgery/radiotherapy to pelvis
Current medication
Lifestyle

13. 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

14. Examination
Genitourinary examination (anatomical abnormalities, size of testes)
Pulses (femoral), BP
Rectal examination (over 50yrs)

15. 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

16. Indications for referral
Endocrine abnormality
Young patients with trauma
Penile disorder/abnormality
Complex cases
Patient/partner request for specialist tests/treatment

17. 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)

18. Treatment Hormonal: testosterone failure – give testosterone
Post-traumatic arteriogenic: surgery
Psychogenic: underlying problem, sex therapy/counselling, phosphodiesterase type-5 inhibitors (sildenafil, tadalafil, vardenafil)

19. 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

20. 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

21. 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)

22. 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.

23. 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)