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Erectile Dysfunction

Erectile Dysfunction. Tom Havard 2013 Great Western Hospital GPST Teaching. History . Impotentia coeundi Chinese 2500BC: Yin-Yang, herbs, acupuncture. Egyptians 1600BC: Ground crocodile hearts, lotus flowers aphrodisiac ( apomorphine )

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Erectile Dysfunction

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  1. Erectile Dysfunction Tom Havard 2013 Great Western Hospital GPST Teaching

  2. History • Impotentiacoeundi • Chinese 2500BC: Yin-Yang, herbs, acupuncture. • Egyptians 1600BC: Ground crocodile hearts, lotus flowers aphrodisiac (apomorphine) • 300BC-1800s: Spanish Fly (cantharidin). Augustus Caesar, Henry IV, Marquis De Sade • 1200s: Witchcraft • 1873: First surgical treatment, blocking veins.

  3. History • 1918: Implanting monkey testicle, then cadavers, goats, boars, deer. • Early 20th Century: Electric shock treatment. • 1935 Holland: Discover Testosterone. • 1960s: Penile implants • 1970s: Penis pumps • 1980s: Injections • 1994: Viagra

  4. Erectile Dysfunction • Inability to initiate or maintain an erection to ejaculation. • Erection: in tact parasympathetic reflex S2, S3. • Ejaculation: in tact sympathetic L1 root.

  5. Aetiology • Blood Supply • Hormones Nerves Psychological Hormones Blood Supply 70%

  6. Aetiology • Leriche Syndrome • Hypogonadism • Peyronies • Diabetes • Depression, anxiety, stress • Cycling • Spinal cord or caudaequina • Stroke • PD • MS • Traumatic nerve/vascular damage: eg radical prostatectomy, pelvic # • HTN, • SSRIs, antihypertensives • Smoking

  7. Epidemiology • Affects 52% aged 40-70 • 10% complete ED • 70% age >70yrs • Those with ED twice as likely to have MI, 20% higher chance of admission with heart failure, 10% more likely to have stroke

  8. History • When, How… • Early morning erections • Anxieties about sexual matters • Organic causes • Diabetes, EtOH, Drugs, • Relationships, conflicts, communication • Depression

  9. Investigations • Bloods • Glucose • Testosterone, Prolactin • TFTs • Lipids • Routine

  10. Treatment • Dependent on cause • Psychological therapy to reduce anxiety, involving partner • Lifestyle change shows improvement in sexual function in one third of obese men

  11. Drugs • PDE5 Inhibitors thus increasing • cGMP and interaction with NO • Sildenafil (Viagra) • Tadalafil (Cialis) • Vardenafil (Levitra) • Also used for pulmonary HTN • (Revatio), Altitude sickness, mixed • with illicit drugs (beware amyl nitrate), • cut flowers.

  12. Eligible on NHS • Severe pelvic injury • Single gene neurological disease • Spinal cord injury • Spina bifida • Receiving Tx 14/09/98 • Impotence causing severe distress (after hospital assessment) • Diabetes • MS • Parkinsons • Poliomyelitis • Prostate Ca • Prostatectomy incl TURP • Radical pelvic surgery • Renal failure treated by • dialysis or transplant

  13. Contraindications • Organic nitrates • Hypotension <90/50. Careful use with alpha blockers • Severe hepatic impairment • Hereditary degenerative retinal disorders eg retinitis pigmentosa • Recent stroke or MI • Careful use with other • P450 inhibitors eg • cimetidine

  14. Sublingual Apomorphine • Dopamine agonist • Not as effective as Sildenafil • Only licensed oral drug not absolutely contraindicated for use with nitrates • Positive response in 40-50% patients

  15. Intracavernosal Injections • Alprostadil, Prostaglandin E1 causes vasodilation • Effective in up to 80% • Few contraindications or interactions • Requires training, manual dexterity, • eyesight • Pain on injection • Also used to maintain patent • ductusarteriosus

  16. Transurethral Alprostadil • Effective in 10mins, lasts 20-60mins • Less effective than intracavernosal and slower acting, but less incidence of priapism

  17. Vacuum Devices • Plastic cylinder, vacuum created by hand or electric pump • Constriction ring around base of penis • Reported long term success in up to • 60% of patients

  18. Penile Prostheses • Two types • Malleable pair of rods with metal core • Inflatable cylinders with internal • pump and reservoir • For patients that have failed to • respond to other treatments or have • developed fibrosis • Risk of infection, erosion through the • glans

  19. Clinical Evidence Review • Evidence of benefit: • Alprostadil (both intracavernosal and transurethral), Apomorphine, Sildenafil, Tadalafil, Vardenafil • Likely to be beneficial: • Ginseng, prosthesis, psychosexual counselling, vacuum devices, yohimbe bark

  20. Referral From Primary Care • Urology • Young men that have always had difficulty • Hx of trauma (genitals, pelvis, spine) • Clinical abnormality (micropenis, peyronies) • Fail to respond to at least 2 max dose PDE5 Inhibitors • Endocrinology • Hypogonadism, abnormal testosterone, • prolactin • Cardiology • Disease making sex or PDE5 use unsafe • Psychologists

  21. Summary • Common – 52% aged 40-70 • Multiple causes • Take comprehensive history • Investigate cardiovascular disease • Consider psychological management • Multiple treatments – First line Sildenafil • Check if qualifies for NHS treatment and contraindications • Refer as approprtiate

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