1. Dr. Anmar Nassir, FRCS(C) Fellowship in Andrology (U of Ottawa) Fellowship in EndoUrology and Laparoscopy (McMaster Univ) Chairman, Department of Surgery Umm Al-Qura Univ Consultant Urology, King Faisal Specialist Hospital, Jeddah

2. Introduction Chronic renal failure causes a wide-ranging disturbance in men including sexual dysfunction. Historically, the prevalence of ED among renal failure patients varied : 40 to 90% Many recent studies reported similar prevalence (80- 86%) of sexual dysfunction in male patients while on HD. Levy 1972, Abram 1975 Ali 2005, Rosas 2003, Neto 2002, Neya 2002, Aeslan 2002, Rosas 2001, Rosas 2000

3. This wide range perhaps because of different questionnaires used in addition to variable sample size Not all studies followed the accurate definition of ED as a persistent inability to achieve or maintain an erection sufficient to permit satisfactory sexual performance. Ali 2005

4. There is not enough data about the effect of modern dialysis therapy on sexual function. data is controversial about whether dialysis is helpful or harmful.

5. Retrospectively, most studies documented no relationship between the duration of dialysis and severity of ED. One study demonstrated a significant correlation between the duration of dialysis and the presence of ED among HD patients. Ali 2005 Mehrsai 2006, Soykan 2005, Miyata 2005, Rosas 2003, Neto 2002, naya 2002, Cerqueira 2002, Arslan 2002, Toorian 1997, Steele 1996, Rodger 1984

6. Prospectively, a study on 25 male patient given a sexual questionnaire twice in a period of 6 month to examine the ongoing effect of dialysis on ED and observed no significant improvement. Criticism : This study only looked at a subset of a small number mixed of both genders. They did not assess the patients on entry to dialysis, but randomly at any time between 12–192 months of HD, with a mean of 67 +/- 46.4 months. Soycan 2005

7. In other words: Many previous studies failed to adopt standard criteria to define impotence or to subcategorize sexual dysfunction. Absence of longitudinal studies planned to evaluate the impact of various renal failure therapies on ED.

8. Objectives  To determine the prevalence of sexual dysfunction in patients treated for renal failure.  To identify the contributory risk factors.  To determine the effect of standard renal failure treatment on sexual function, while on dialysis or post transplant.

9. Materials & Methods Prospective study Started in 1998 with a follow up divided in stages. On admission to dialysis Every 10-12 months while on dialysis or post kidney transplantation.

10. Materials & Methods The questionnaire used: The international index of erectile function (IIEF) with its 5 domains, used to develop a semiquantitative baseline score useful in follow up. Other questions specially designed for our objectives were added.

11. Results Population: 52 pts (at NS, Canada) fulfilled the criteria and returned 149 Questionnaire. 52 filled 1 questionnaire, 45 filled 2 questionnaires 34 filled 3 questionnaires 15 filled 4 questionnaires 4 filled 5 questionnaires Mean age was 58.5 +/- 14.3 (SD)

12. Results  Renal Failure Therapy:  25 HD + 27 PD.  During f/u 16 pts received a Kidney Transplant.  F/U ranges from 0 to 48 months (average =20.5)  14 patients died during f/u.  The rest had a mean f/u of 26 months.

13. Erectile Function  On entry to dialysis: 82.7 % have ED Only 17.3 % were potent  Severity

14. Kidney Transplantation Some authors claimed that prevalence of ED in transplanted men was not significantly lower than in dialysis patients. Better designed studies, based on the IIEF-5 scores of 64 patients: 78.1% improved, 12.5% experienced no change 9.4% had a lower score. Toorians 1997 Mehrsai 2006

15. Kidney Transplantation In a cross sectional study on 243 transplanted patients, ED was found in 54.9%. Factors independently associated with ED were: age, time on dialysis prior to transplant, and peripheral arteriopathy. Our data supported the beneficial effect of transplantation on sexual function with an advantage continued in a chronological prospect. Unmeasured variations in the previous studies probably resulted in the differences. Rebollo 2003

16. Evaluation H & P IIEF-5 Ix: Lab: CBC, Hb1ac, cholesterol, prolactin, Testosterone

17. Treatment

18. 66.6 % of ED pt are welling to have it treated. Only 12 % of ED pt had trt for it. Half of them received it at >30 months of f/u

19. Significant observations Among the 5 domains of IIEF, sexual desire was relatively less affected. 35 patients with ED (66.6 %) were willing to be treated. Only 6 patients with ED (12%) received treatment.

20. Although it is a major factor affecting quality of life in end stage renal disease (ESRD), SD in dialysis patients receives very limited attention by the medical team. Despite its importance, only 25% of patients discuss sexual function with their physicians Soykan 2005 Diemont 2000

21. Treatment The reason for not seeking medical help is probably related to the high prevalence of psychological depression. This high prevalence is well documented. Peng 2007, Kimmel 2000

22. Treatment – why not ? There was significant correlation between the total score of IIEF and daily activities, social activities, social support, quality of life. Some patients without sexual activity didn’t perceive their deficiency as a problem and considered this situation inherent to the ageing process. Martín-Díaz 2006

23. Treatment Among different modalities treating ED in ESRD patients, the simplest is using oral medication. Most studied were done on Sildenafil.

24. Treatment by Sildenafil It is recommended to be used on days off dialysis. Next day after HD has better efficacy. Some authors showed that ED in two-thirds of HD patients can improve by sildenafil. Yenicerioglu 2002

25. Treatment using Sildenafil Yenicerioglu 2002

26. Treatment using Sildenafil Yenicerioglu 2002

27. Treatment using Sildenafil Yenicerioglu 2002 The ROC curve of the erectile function domain score before treatment for predicting the outcome of sildenafil treatment in patients with ESRD (area under the curve, 0.790) ROC = (receiver operating characteristic)

28. Treatment using Sildenafil For the erectile function domain the ROC curve patients with a score of ≥ 17 seem to respond better to sildenafil treatment (with a sensitivity of 71% and a specificity of 67%). Yenicerioglu 2002

29. The response rate was 80% in those using HD when advised to take pills only on days with no dialysis; Some authors reported transient hypotension after a 50-mg dose of sildenafil in patient on HD patients may remain relatively hypovolaemic for some time after dialysis, they recommended that sildenafil should be used on days with no dialysis. Mohamed et al. 2002

30. Treatment using Sildenafil Recommendation: All patients were started on a 25-mg dose, Increased to 50 mg if there was no response after two trials. Yenicerioglu 2002

31. Double-blind, randomized, placebo-controlled study 50 mg sildenafil Inclusion: patients with ED. Patients on HD for at least 6 mo With stable relationship with a female sexual partner SEIBEL et al, 2002

32. Exclusion: Patients older than 70 yr penile anatomic abnormalities, cirrhosis, diabetes, angina, severe anemia, on nitrate treatment recent history of stroke or MI. SEIBEL et al, 2002

37. Treatment When subdivided, diabetic patients responded less (37.5%) compared to non diabetics (83.3%). Hyodo 2004

39. Side effects Side effects - Sildenafil side effect At least one side effect was seen in 17/40 patients (43%); 5/40 (13%) pts reported more than one side-effect 1 pt  severe hypotension in the PD group. 12 pt (30%)  flushing. 7 pts (18%)  mild headache 1 pt  blurred vision Yenicerioglu 2002

40. Salvage Treatment 12 patients (8 Tx- & 4 HD) who complained of ED with hypogonadism and cavernosal insufficiency. Before treatment all patients had severe ED with a poor IIEF score 11 had diminished libido. 11 pts had diminished testicular volume 6 had elevated FSH Chatterjee 2004

41. Salvage Treatment Received 250 mg IM/m testosterone cypionate and 50–100 mg sildenafil orally once or twice / w 12 mo All patients had a good response Chatterjee 2004

43. Sildenafil in Kidney Tx Even after renal transplant, those patients who still suffer from ED Sildenafil can be effective in 60%. Multictr phase IV 50 pt post Tx w ED Sildenafil: 50 mg then inc or dec X 3 mo Barrou 2003 Castro 2001

44. 65 ED patients with normal graft function for 3-12 months after kidney Tx were involved in our study. Erectile dysfunction was diagnosed in all the patients by the IIEF. Among them, 10 patients were in light degree; 32 patients in moderate degree, 23 patients in severe degree according to IIEF score. Zhang et al, 2005 Sildenafil in Kidney Tx

45. In each patient, the IIEF score, were compared before and after taking sildenafil citrate at an initial dose of 50 mg every night. Zhang et al, 2005 Sildenafil in Kidney Tx

46. Results 26 patients without ED before transplantation suffered ED after the operation, 32 patients with ED before transplantation noticed worsening. Taking sildenafil citrate was effective in 53 patients (81.54%). Zhang et al, 2005 Sildenafil in Kidney Tx

47. Zhang et al, 2005 Sildenafil in Kidney Tx

48. Barrou 2003

49. Sildenafil in Kidney Tx 66% of patients believed treatment had improved their erections. Patients reported improvements in their sexual life and partner relationships and a high level of satisfaction with treatment Barrou 2003

50. Sildenafil in Kidney Tx 30/ 51 patients (58.8%) presented with at least one SE during the study. Most of them were mild to moderate. Barrou 2003

51. Sildenafil in Kidney Tx 5 patients (9.8%) presented with at least one serious adverse event, which led to 3 patients being withdrawn from the study. 2 of the serious SE were considered possibly attributable to the study drug. 1 pt  angina pectoris 1 day after the beginning of treatment 1 pt  non-serious aggravated depression. Barrou 2003

52. Sildenafil in Kidney Tx At the end of the study: 27 patients (53%) were taking a dose of 100 mg/day, 1 patient (2%) was taking a dose of 75 mg/day, 22 patients (43%) were taking a dose of 50 mg/day one patient (2%) was taking a dose of 25 mg/day. The average number of tablets taken per week between inclusion and the end of the study was 3.3+/- 1.7 tablets. Barrou 2003

53. Conclusions As life expectancy for these patients continues to improve and given the availability of oral medication for ED, physicians are urged to acknowledge the high prevalence of ED in ESRD and proactively question all patients with ESRD regarding their ED. This will improve the recognition of this condition among these patients, which can lead to adequate treatment and improved quality of life. Neto 2002

54. Conclusions  Sexual dysfunction is very common among patients who have dialysis dependant renal failure.  Sexual dysfunction is not altered by dialysis therapy.  Renal Transplantation may improve erectile function.

55. Conclusions  Early evaluation of sexual function upon entry to dialysis is necessary.  Provision of effective therapy to those with ED needs to be improved.