Evaluation and Treatment of Erectile Dysfunction

Michael P. Finkelstein, M.D.

Man survives earthquakes, experiences the horrors of illness, and all of the tortures of the soul. But the most tormenting tragedy of all time is, and will be, the tragedy of the bedroom. Tolstoy

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

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.

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

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

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.

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

An Erection Requires a Coordinated Interaction of Multiple Organ Systems

Psychological Endocrine Vascular Neurologic

Mechanism of Smooth Muscle Relaxation

Release of Neurotransmitters-nitric oxide Conversion of GTP to cGMP - erection Breakdown of cGMP by PDE type 5 detumesence

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

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

Causes of ED
Risk Factors Massachusetts Male Aging Study

Treated heart disease Treated diabetes Treated hypertension

Feldman Ha, J Urol 1994; 151:54-61

39% 28% 15%

Causes of ED Other risk Factors

Diabetes 27% - 59% Chronic renal failure 40% Hepatic failure 25% - 70% Multiple Sclerosis 71% Severe depression 90% Other (vascular disease, low HDL, high cholesterol)

Benet et al. Urol Clinic North Am. 1995; 151:54-61

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

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

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

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

Causes of ED
Medications (cont.) CNS drugs:
Antidepressants, tricyclics, SSRIs Tranquilizers Sedatives Analgesics

H1 and H2 receptor blockers

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

A Practical Evaluation of Men with ED Basic evaluation

Medical History Cardiovascular history Endocrine history Sexual history/questionnaire

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

A Practical Evaluation of Men with ED Sexual History

Premature ejaculation Retarded ejaculation Painful intercourse Anorgasmia Decreased Libido Dissatisfaction with sex life

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?

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?

A Practical Evaluation of Men with ED ED Questionaire

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?

The International Index of Erectile Function, Urol 1997;49:822-830

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?

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

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

A Practical Evaluation of Men with ED Physical Examination

Blood pressure Examine penis (R/O Peyronies disease) Determine size and consistency of testes Digital rectal exam Focused vascular exam/peripheral pulses Focused neurologic exam

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

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)

Treatment Options Goal directed therapy

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

Lue TF, World J. Urol 8:67,1990

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

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

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

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

Ideal Medication for Treatment of ED

Effective Available on demand Free of toxicity and side effects Easy to administer Inexpensive

Medication (Viagra, Levitra, Cialis)

Mechanism of Action: PDE inhibitor and increases the cGMP that promotes and sustains smooth muscle relaxation

Medication (PDE Inhibitors)

Indications: Psychogenic ED Mild vasculogenic ED Neurogenic ED Side effects from medication(s) patient is already taking

Medication (PDE Inhibitors)

Side effects: Headache Flushing Dyspepsia Nasal congestion Visual disturbances Priapism

Medication (PDE Inhibitors)

Contraindications: Organic Nitrites:
Oral Sublingual

Severe cardiac disease

Obtain stress testing

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

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

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

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

Medication Side effects

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

Transurethral Therapy Alprostadil - MUSE

Mechanism of Action: vasodilator Administration: 125, 250, 500. 1000ug Insert in the urethra Erection occurs 10-15 minutes later Erection lasts 30-45 minutes Results: 10-65% Side effects: Pain, bleeding, priapism (<3%)

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

Androgen Replacement Therapy

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

Androgen Replacement Therapy

Avoid in patients with prostate or breast cancer Slight increase risk of BPH Monitor all patients with annual DRE and PSA

Vacuum Constriction Device

Mechanism of Action: Penis placed in plastic tube Air evacuated from the tube Blood trapped in penis with constricting ring

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

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

Penile Prosthesis
Indications: Patients who have failed other therapies Peyronies disease Severe vasculogenic disease

Choosing a Penile Prosthesis

Considerations: Medical condition Lifestyle Cost Insurance coverage As with all prescription products, complications are possible

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

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

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

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

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

Penile Prosthesis
Disadvantages: Surgery Expensive Possible mechanical failure

Penile Prosthesis Insurance Reimbursement

Covered by most companies, including Medicare No co-payment for men with Medicare supplemental insurance

When to Refer to a Urologist

Refer Patients to a Urologist

Patients who fail medical management Patients with Peyronies disease Patients with severe vasculogenic ED Patients on NTG who are not candidates for oral medications Patients requesting an implant

Why Refer to a Urologist?

Only specialty that is trained in andrology and/or management of ED Urologists offer a range of treatment options ED represents a significant aspect of many urologic practices Urology support staff is comfortable treating men and their partners who suffer from ED

Summary
ED is a common problem that affects millions of American men ED can be easily evaluated by the PCP ED can be treated with oral medications by the PCP Patients that do not respond to medical therapy should be referred to a Urologist Penile prosthesis is an effective means of treating ED

Remember
Primary care physician should consider early referral to Urologist if initial treatment is not successful No one needs to suffer the tragedy of the bedroom

Any Questions?