Dr. Mohammed Othman Al-Rukban DPHC; ABFM; SBFM Consultant Family Medicine, KSU

1. Dr. Mohammed Othman Al-Rukban DPHC; ABFM; SBFM Consultant Family Medicine, KSU

2. Content WHY this topic. Define erectile dysfunction (ED) Discuss the most common causes of ED Anatomy and physiology. How DM affect sexual function Practical evaluation of men with ED Treatment options Provide suggestions for urologic referral

3. Why assess sexual function: It is a common problem Sexual side effects of medications, illness Can impact treatment decisions and/or compliance with medical treatments Integral component of quality of life, well-being

4. Why in diabetic patient More common in diabetic patients. It affects Quality of life. Can be a predictor factor for illness.

5. Sexual Dysfunction The three major forms of male sexual dysfunction are: Erectile dysfunction. Decrease libido Ejaculatory dysfunction

6. Multifactorial: Biomedical, Psychological, Social Factors Challenge in diagnosing and treating sexual problems: multiple factors affect sexual functioning. Sexuality is an important topic for all health care providers. Biopsychosocial phenomenon, and it is the interaction of physical, emotional, and relational factors that leads to healthy or dysfunctional sexual responding. This conceptualization is important for 2 reasons: (1) assuming only a single cause will likely interfere with effective treatment planning (2) setting up a mind-body dichotomy for our patients is inaccurate and may alter motivation for and success of interventions. A Sexual history and knowledge of current functioning is especially useful information for those of us in the mental health field: Sexual satisfaction can contribute to relationship satisfaction, which is protective for mental and physical health. Many mental disorders have a negative impact on sexual functioning either directly via impaired interpersonal functioning or the sequelae of past abuse, or indirectly because of the toll they take on relationships. (3) Many psychiatric medications cause sexual difficulties. Challenge in diagnosing and treating sexual problems: multiple factors affect sexual functioning. Sexuality is an important topic for all health care providers. Biopsychosocial phenomenon, and it is the interaction of physical, emotional, and relational factors that leads to healthy or dysfunctional sexual responding. This conceptualization is important for 2 reasons: (1) assuming only a single cause will likely interfere with effective treatment planning (2) setting up a mind-body dichotomy for our patients is inaccurate and may alter motivation for and success of interventions. A Sexual history and knowledge of current functioning is especially useful information for those of us in the mental health field: Sexual satisfaction can contribute to relationship satisfaction, which is protective for mental and physical health. Many mental disorders have a negative impact on sexual functioning either directly via impaired interpersonal functioning or the sequelae of past abuse, or indirectly because of the toll they take on relationships. (3) Many psychiatric medications cause sexual difficulties.

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

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

9. Causes of EDOther 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

10. Causes of ED Medications may be responsible for ~25% of cases of ED Substance abuse Alcohol Smoking amplifies other risk factors Bicycle riding (long distance)

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

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

13. Causes of ED Medications (cont.) CNS drugs: Antidepressants, tricyclics, SSRIs Tranquilizers Sedatives Analgesics H1 and H2 receptor blockers

14. Incidence And Prevalence 20-30 million American men suffer ED Age dependent 2% men age <40 years (6% at 25 years in DM) 25% men age 65 (50% at 55 years in DM) 75% men >75 years Not a necessary occurrence of the aging process

15. It occurs earlier Erectile dysfunction most frequently develops after age 65. In men with diabetes, it tends to occur 10 or 15 years earlier. Men in their 30s and younger with diabetes have also experienced erectile dysfunction.

16. It occurs more often As many as 75% of men with diabetes (35-75%) develop erectile dysfunction, compared to about 22 – 25% of men without diabetes.

17. Massachusetts Male Aging Study The age adjusted probability of complete impotence was three times greeter (28%) in patients with treated diabetes than in those without diabetes (9.6%). J Urol 151:54-61,1994

18. Association of Type and Duration of Diabetes With Erectile Dysfunction The longer you've had diabetes and the more severe it is, the more likely you are to develop erectile dysfunction. The risk is more with type1 diabetes than type 2 (RR=3 vs 1.3) respectively. Diabetes care 25: 1458-1463,2002

19. What is ED? ED : is the persistent/recurrent inability to attain/maintain an adequate erection to completion of sexual activity ( If more than 75% of time ---> Impotence)

20. Longitudinal Assessment of Quality of life in patients with diabetes 1456 patients involved. Among patients who develop ED during the study there was: 1- Deterioration of all SF-36 dimensions. 2- Worsening in depressive symptoms. 3- Worsening of physical and social functioning. Diabetes Care 28:2637-2643, 2005

21. Erectile Dysfunction and Quality of Life in Type 2 Diabetic Patients Involved 1460 patients, ED was found to be: 1- Associated with higher levels of diabetes-specific health distress 2- Worse psychological adaptation to diabetes< worse metabolic control. 3- Increase prevalence of major depression. 4- Lower scores in mental evaluation. 5- 65% reported their physician had never investigated their sexual problems. Diabetes Care 25:284-291,2002

22. ED: take the lead It is very important therefore, to remember that the primary care physician is well placed to treat ED: in most cases, diagnosis is simple and need not be time-consuming first-line treatments are suitable for initiating in the primary care setting primary care physicians can often have good rapport with their patients which will permit sexual matters to be discussed without embarrassment but they need to take the lead and can discover that successful treatment of ED will greatly reinforce the doctor/patient relationship. It is very important therefore, to remember that the primary care physician is well placed to treat ED: in most cases, diagnosis is simple and need not be time-consuming first-line treatments are suitable for initiating in the primary care setting primary care physicians can often have good rapport with their patients which will permit sexual matters to be discussed without embarrassment but they need to take the lead and can discover that successful treatment of ED will greatly reinforce the doctor/patient relationship.

23. Predictor of illness ED may be a predictor of silent myocardial ischemia in men with diabetes (1). ED may be an early sign of future cardiovascular events. (2,3) Men in whom erectile dysfunction persisted were more likely to develop retinopathy or neuropathy (4). 1. Circulation 2004; 110:22 2. J Am Coll Cardiol 2005; 46:1503 3. JAMA 2005; 294:2996 4. Diabetologia 1980; 18:279

24. Anatomy of the penis Two corpora cavernosa (cylindrical, sponge-like structures that run along its length( make up the bulk of the erectile tissue of the penis. The corpus spongiosum is a chamber that surrounds the urethra and becomes engorged with blood during an erection. An artery runs deep through the center of each corpus cavernosum, allowing blood to flow in. Blood flows back out through a system of veins around the outside of each corpus cavernosum.

27. Physiology-1 Normal sexual function requires the coordinated Interaction of: nervous, endocrine and vascular systems. physical, sensory and psychological events. After stimulation< the body releases neurotransmitters such as nitric oxide in the penile area < smooth muscle relaxation < widening of the central artery and other blood vessels, and blood rushes into the penis.

28. Physiology -2 As the corpora cavernosa fill with blood, the spongy tissue presses up against the veins, compressing them and preventing blood from flowing out of the penis. That produces an erection. When the stimulation ends, the muscles contract, pressure decreases < increase venous outflow.

29. How diabetes affects normal sexual function Diabetes can cause neuropathy or damage to nerves. Damaged nerves can't communicate properly and doesn't respond. Poor blood sugar control can inhibit nitric oxide production. Vasculopathy (atherosclerosis)

30. A Practical Evaluation of Men with EDHistory Onset Frequency Severity Morning erection Assess risk factor (chronic illness, trauma, smoking, psychological assessment……..) Drug history (8 out of 12 most common prescribed drugs, listed impotence as SE)

31. 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

32. 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

33. A Practical Evaluation of Men with EDPhysical Examination General exam (BP, BMI…..) Examine penis Determine size and consistency of testis Digital rectal exam Focused vascular exam/peripheral pulses Focused neurologic exam Visual field defects > hypogonadal men with pituitary tumors Breast for gynecomastia > Klinefelters syndrome

34. A Practical Evaluation of Men with EDLaboratory Tests FBS and HbA1c UA (Albuminurea). Lipid profile, Liver function, Creatinine. PSA in men over 50 Testosterone (best to draw in A.M.) Prolactin, Thyroid function,

35. A Practical Evaluation of Men with EDOther Tests NPT – Nocturnal Penile Tumescence Test Penile doppler Nerve study

36. Treatment Options Nonpharmacological Pharmacological Non-invasive Minimally invasive Invasive Counseling

37. REACH optimum management: discuss and decide on treatment options First-line therapies Oral erectogenic agents Other vacuum constriction devices sexual counselling and education Second-line therapies Intraurethral injection of alprostadil Intracavernosal injection of alprostadil Third-line therapy Surgical implantation of prosthesis Having determined the diagnosis, a brief discussion on alternative first-line treatments is required. It is also useful at this time to explain that if first-line therapies are unsuccessful then other treatments can be tried. Having determined the diagnosis, a brief discussion on alternative first-line treatments is required. It is also useful at this time to explain that if first-line therapies are unsuccessful then other treatments can be tried.

38. Nonpharmacologic Treatment Options Lifestyle changes: Reduce fat and cholesterol in diet Eliminate tobacco and alcohol use and substance abuse Weight loss if appropriate (30% improvement) Regular exercise Control other chronic illness (DM, HTN, Lipids, Depression……)

39. Psychosexual counseling Although most men with diabetes have one or more organic causes for their erectile dysfunction, psychological factors are also often present. Psychosexual counseling may be not effective alone in patients with diabetes. Helpful as an adjunct to drug therapy.

40. Pharmacological treatment Several treatments for erectile dysfunction available, non of which is specific for diabetes.

41. Medication(Viagra, Levitra, Cialis) First line therapy for erectile dysfunction effective (69 vs 22% with placebo) Mechanism of Action: PDE (phosphodiesterase) inhibitor Increases the cGMP that promotes and sustains smooth muscle relaxation ( prolong the vasodilatory effect of nitric oxide to initiate and maintain erection).

43. Medication(PDE Inhibitors) Indications: Psychogenic ED Mild vasculogenic ED Neurogenic ED Side effects from medication(s) patient is already taking

44. Medication (PDE Inhibitors) Side effects: Headache Dizziness Flushing Dyspepsia Nasal congestion Visual disturbances (sildenafil) Priapism

45. Medication (PDE Inhibitors) Contraindications: Using Nitrites: Oral Sublingual Severe cardiac disease ACC and AHA > safe for men with stable CAD who are not taking nitrares. Obtain stress testing

52. When to Refer to a Urologist

53. Refer Patients to a Urologist Patients who fail medical management Patients with severe vasculogenic ED Patients who are not candidates for oral medications Patients requesting an implant

54. Female Sexual Dysfunction in Diabetic Pt Introduction: NHSLS 1999: 1/3 lack of intrest 20% lubricant diff Leiblum,1992: 30-40% unable to achieve orgasm without concurrent clitoral stim. 5-8% totally unable to achieve orgasm with any stim.

55. Summary ED is a common problem. 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