1. Erectile Dysfunction Dr S Vas 2015

2. Learning Outcomes Understand what ED is Describe the causes of ED List relevant investigations Describe treatment in Primary Care Identify those patients requiring refarral to Secondary Care

3. Definition Erectile dysfunction is defined as –the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance Symptoms lasting 3 months should warrant further investigations/treatment

4. Prevalence 52% of men aged 40 to 70 reported some degree of ED On average a GP will see between 1 and 4 cases per month

5. Causes - Physical Vascular – cardiovascular disease, hypertension, hyperlipidaemia, diabetes mellitus, smoking Neurological – Multiple sclerosis, multiple atrophy, Parkinson's disease, tumours, stroke, spinal disorders, diabetes mellitus, alcoholism, uraemia, polyneuropathy, surgery (of the pelvis or retroperitoneum) Anatomical or structural – Peyronie's disease, penile fracture, congenital curvature of the penis, micropenis, hypospadias, epispadias Hormonal – Hypogonadism, hyperprolactinaemia, hyperthyroidism, hypothyroidism, Cushing's disease, hypopituitarism following traumatic brain injury

6. Causes - Medication Diuretics – Thiazides (for example bendroflumethiazide), spironolactone Antihypertensives – Methyldopa, clonidine, beta-blockers (for example propranolol), verapamil Fibrates – Clofibrate, gemfibrozil Antipsychotics – Phenothiazines (for example chlorpromazine), butyrophenones (for example haloperidol) Antidepressants – Tricyclics (for example amitriptyline), monoamine oxidase inhibitors (for example phenelzine), selective serotonin reuptake inhibitors (for example fluoxetine), lithium Histamine (H2)-antagonists – Cimetidine, ranitidine Hormones and hormone-modifying drugs – Oestrogens (for example estradiol), progesterone, corticosteroids (for example prednisolone), cyproterone acetate, 5-alpha reductase inhibitors (for example finasteride) Cytotoxics – Cyclophosphamide, methotrexate Anti-arrhythmics and anticonvulsants – Disopyramide, carbamazepine

7. Causes - Psychological Various factors –Lack of sexual knowledge –Past sexual problems –Relationship problems –Restrictive upbringing –Previous sexual abuse –Unclear sexual or gender preference –Family or social issues –Mental health issues

8. History Relationship status (current and past) and sexual orientation Present and previous erection quality (including erections during sexual relations as well as awakening and masturbatory erections), and concomitant ejaculatory and orgasm dysfunction. Issues with sexual aversion or pain, or issues for his partner (including menopause or vaginal pain). Lifestyle, including use of alcohol, tobacco, and illicit drugs (including cannabis), and treatments already tried. Energy levels, loss of libido, loss of body hair, or spontaneous hot flushes (symptoms of hypogonadism).

9. Examination Body weight, waist circumference, blood pressure and pulse Genitalia +/- DRE (if symps of enlarged prostate)

10. Investigations Fasting Lipids/Glucose for CVD risk Testosterone (between 9 and 11 am) If Testosterone low or borderline check: –Repeat Testosterone –LH/FSH/Prolactin

11. Self Care Advice Lifestyle changes –Weight loss,smoking cessation, reduced alcohol and exercise Changes to medication –Only consider changing if appropriate substitute PDE-5 inhibitors If cycle > 3 hrs week consider “abstaining” Do not advise “unlicensed” herbal remedies

12. Questions?

13. Medical Treatment PDE-5 inhibitors –Sildenafil (Viagra) – effects last 4 hrs –Tadalafil (Cialis) – effects last 4 hrs –Vardenafil (Levitra) – effects last 17 hrs (“weekend- warrior”) Contra-indications –Absolute in men receiving Nitrates in any form –Unstable heart disease, recent MI (within last 6 months), poorly controlled heart failure, unstable arrythmia –+ other more specific risk factors

14. SLS Criteria Diabetes MS Parkinson’s Disease Poliomyelitis Prostate Cancer Severe Pelvic Injury Spina Bifida Spinal Cord Injury Single Gene Neuro Disease i.e. Huntingdon’s Disease Renal dialysis for renal failure Radical Pelvic Surgery, Prostatectomy or Renal transplant

15. Referral Criteria Endocrine Referral –Men with hypogonadism (i.e. low testosterone levels) Urology Referral –Abnormality to the penis or testicles –Young men who have always had difficulty in obtaining or maintaining an erection – Men with a history of trauma (for example to the genital area, pelvis, or spine) – Men who do not respond to the maximum dose of at least two phosphodiesterase-5 (PDE-5) inhibitors (person with erectile dysfunction should receive eight doses of a PDE-5 inhibitor with sexual stimulation at maximum dose before being classified as a non-responder)