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ED Dr Saqib Mahmud MRCP(UK), MRCPS(Glasg), MRCGP.

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Presentation on theme: "ED Dr Saqib Mahmud MRCP(UK), MRCPS(Glasg), MRCGP."— Presentation transcript:

1 ED Dr Saqib Mahmud MRCP(UK), MRCPS(Glasg), MRCGP

2 ED-inability to achieve/maintain an erection sufficient for mutually satisfying intercourse Incidence- increase with age Incidence- increase with age 39% men aged 40yrs, 67% age 70yrs 39% men aged 40yrs, 67% age 70yrs Present worldwide prevalence>150 million men, double in next 25yrs >300 million men by 2025 Present worldwide prevalence>150 million men, double in next 25yrs >300 million men by 2025 Previously thought of inorganic origin, now believed that ED is increasingly due to organic disease Previously thought of inorganic origin, now believed that ED is increasingly due to organic disease

3 Mechanism of erection Largely a vascular event Largely a vascular event In response to sexual stimuli, parasympathetic nervous system dilates cavernosal arteries & relaxes trabecular smooth muscle  increased blood flow  filing sinusoidal spaces engorge penis (tumescence)  compress & stops venous outflow maintaining the erection In response to sexual stimuli, parasympathetic nervous system dilates cavernosal arteries & relaxes trabecular smooth muscle  increased blood flow  filing sinusoidal spaces engorge penis (tumescence)  compress & stops venous outflow maintaining the erection Reverse of these events after ejaculation  sympathetic activity--.contraction of arteries & trabecular smooth muscle--.venous outflow  decompression of venous channels (detumescence) Reverse of these events after ejaculation  sympathetic activity--.contraction of arteries & trabecular smooth muscle--.venous outflow  decompression of venous channels (detumescence)

4 Chemical pathways in penile erection Most important NO-induced cGMP pathway Most important NO-induced cGMP pathway Endothelial cells release NO in response to sexual stimuli Endothelial cells release NO in response to sexual stimuli NO increases cGMP, which relaxes the corpus cavernosal smooth muscle leading to an erection NO increases cGMP, which relaxes the corpus cavernosal smooth muscle leading to an erection Detumescence occurs when cGMP is broken down by an enzyme ‘’phosphodiesterase’’(PDE- 5)  hence the role of PDE5 inhibitors in maintaining the erection Detumescence occurs when cGMP is broken down by an enzyme ‘’phosphodiesterase’’(PDE- 5)  hence the role of PDE5 inhibitors in maintaining the erection

5 causes Vascular-endothelial dysfunction, atherosclerosis, htn, hypercholesterolemia Vascular-endothelial dysfunction, atherosclerosis, htn, hypercholesterolemia Endocrine-DM, hypothyroidism, hyperprolactinaemia, testosterone deficiency, hormonal imbalance due to hepatic & renal disease Endocrine-DM, hypothyroidism, hyperprolactinaemia, testosterone deficiency, hormonal imbalance due to hepatic & renal disease Neurological-MS, CVA, Parkinson’s, Alzheimer’s, spinal cord & brain injuries Neurological-MS, CVA, Parkinson’s, Alzheimer’s, spinal cord & brain injuries Peyronie’s disease- rare inflammatory condition->scaring of erectile tissue- >painful erection Peyronie’s disease- rare inflammatory condition->scaring of erectile tissue- >painful erection

6 Drugs->200 commonly prescribed drugs can cause or contribute to ED Beta-blockers Beta-blockers Diuretics-BFZ, furosemide Diuretics-BFZ, furosemide ACEI ACEI CCB CCB LH-RH analogs LH-RH analogs Antiandrogens Antiandrogens Benzodiazepines Benzodiazepines Alcohol Alcohol Illicit drugs Illicit drugs

7 Other causes of ED Pelvic trauma Pelvic trauma Radiotherapy Radiotherapy Colorectal, prostate & bladder surgery increases the risk of ED Colorectal, prostate & bladder surgery increases the risk of ED Vascular leak- veins unable to constrict efficiently during erection Vascular leak- veins unable to constrict efficiently during erection Substance abuse- chronic use of cocaine, marijuana, alcohol, steroids Substance abuse- chronic use of cocaine, marijuana, alcohol, steroids Excessive use of tobacco-nicotine in tobacco causes contraction of small blood vessels  less flow to the region->ED Excessive use of tobacco-nicotine in tobacco causes contraction of small blood vessels  less flow to the region->ED

8 Psychological causes of ED Depression Depression Anxiety Anxiety Stress Stress Performance anxiety– anxiety & stress lead to increased production of catecholamine which act as erection inhibitors Performance anxiety– anxiety & stress lead to increased production of catecholamine which act as erection inhibitors

9 Assessment – ED as a marker Study of 980 men with ED found; 18% - undiagnosed HTN 18% - undiagnosed HTN 16% - DM 16% - DM 15% - BPH 15% - BPH 5% - IHD 5% - IHD 4% - Ca Prostate 4% - Ca Prostate 1% - Depression 1% - Depression b/w 39 & 64% of males with CVD suffer from ED

10 Physical Assessment BP BP Femoral & peripheral pulses, femoral bruits – vascular abnormalities / PVD Femoral & peripheral pulses, femoral bruits – vascular abnormalities / PVD Neurological exam – deep tendon reflexes, bulbocavernosis reflex (gentle squeeze of glans  anal contraction), reduced sensation- sacrum, perineum Neurological exam – deep tendon reflexes, bulbocavernosis reflex (gentle squeeze of glans  anal contraction), reduced sensation- sacrum, perineum Visual field defects – prolactinoma, pituitary mass Visual field defects – prolactinoma, pituitary mass Gynaecomastia – hyperprolactinaemia Gynaecomastia – hyperprolactinaemia Testicular atrophy- testosterone def, hypogonadism Testicular atrophy- testosterone def, hypogonadism

11 Assessment - contd Rectal exam – assessment of prostate & sphincter tone Rectal exam – assessment of prostate & sphincter tone PHQ-9 Questionnaire PHQ-9 Questionnaire FBS FBS U&Es, LFTs, TFTs U&Es, LFTs, TFTs Serum testosterone & SHBG, prolactin Serum testosterone & SHBG, prolactin

12 Management of ED PDE5 inhibitors – sildenafil, tadalafil, vardenafil PDE5 inhibitors – sildenafil, tadalafil, vardenafil Sildenafil (1998) - 25mg, 50mg,100mg Sildenafil (1998) - 25mg, 50mg,100mg Taken 1hr before sex, effective up to 4 to 5 hrs, s/e - headache Taken 1hr before sex, effective up to 4 to 5 hrs, s/e - headache Tadalafil (2003) – 10mg, 20mg(PRN) 2.5mg, 5mg(once daily-2009) Tadalafil (2003) – 10mg, 20mg(PRN) 2.5mg, 5mg(once daily-2009) Taken 30 minutes before sex, effective up to 36hrs, s/e - dyspepsia, headache Taken 30 minutes before sex, effective up to 36hrs, s/e - dyspepsia, headache

13 contd Vardenafil(2003) – 5mg, 10mg, 20mg Vardenafil(2003) – 5mg, 10mg, 20mg Taken 25 – 60minutes before sex, effective up to 4 – 5 hrs, s/e – headache, flushing Taken 25 – 60minutes before sex, effective up to 4 – 5 hrs, s/e – headache, flushing

14 When PDE5 inhibitors don’t work Patient Education Patient Education 81% do not take them correctly 81% do not take them correctly Adequate sexual stimulation necessary Adequate sexual stimulation necessary Food & alcohol delay & reduce absorption Food & alcohol delay & reduce absorption Some need 6-8 doses before an optimal response occurs Some need 6-8 doses before an optimal response occurs Psychotherapy integrated with pharmacotherapy Psychotherapy integrated with pharmacotherapy

15 Prescribing advice Switch drugs Switch drugs Optimize dose – increase to max Optimize dose – increase to max Patients unresponsive to PRN Tadalafil, consider once daily regime Patients unresponsive to PRN Tadalafil, consider once daily regime Combine with other drugs; intraurethral alprostadil with PDE5 inhibitors or with doxazocin (weak erectogenic agent) ideal with BPH+HTN patients Combine with other drugs; intraurethral alprostadil with PDE5 inhibitors or with doxazocin (weak erectogenic agent) ideal with BPH+HTN patients

16 Other treatments for ED MUSE – medicated urethral system for erection, pallet of PGE1(alprostadil) inserted in urethra 15min before sex, lasts 30 to 60min MUSE – medicated urethral system for erection, pallet of PGE1(alprostadil) inserted in urethra 15min before sex, lasts 30 to 60min Can be used up to twice daily Can be used up to twice daily s/e – penile pain, burning (32%) s/e – penile pain, burning (32%) 43% efficacy compared to intracavernosal route but less complications such as priapism and penile fibrosis with injections 43% efficacy compared to intracavernosal route but less complications such as priapism and penile fibrosis with injections

17 Vacuum constriction devices SOMACorrect Xtra, SOMAerect Response II SOMACorrect Xtra, SOMAerect Response II One time cost (£160 - £180/-) One time cost (£160 - £180/-) Efficacy – 92% regardless of underlying cause of ED Efficacy – 92% regardless of underlying cause of ED Time to erection onset- 90 to 120 seconds Time to erection onset- 90 to 120 seconds Time required to terminate erectin <30seconds Time required to terminate erectin <30seconds No systemic side effects compared to oral Rx No systemic side effects compared to oral Rx

18 Surgical treatment for ED Penile prosthesis – for patients who probabaly have sufffered physical damage to corpora, renndering other treatments ineffective Penile prosthesis – for patients who probabaly have sufffered physical damage to corpora, renndering other treatments ineffective Vascular surgery – when ED is due to poor arterial inflow or abnormal venous drainage ( arterial revascularization, ligation of venous incompetence) Vascular surgery – when ED is due to poor arterial inflow or abnormal venous drainage ( arterial revascularization, ligation of venous incompetence) Results vary widely but usually poor Results vary widely but usually poor

19 Testosterone therapy Only indicated in men whose loss of libido/ ED is due to hypogonadism or documented low testosterone levels Only indicated in men whose loss of libido/ ED is due to hypogonadism or documented low testosterone levels Testosterone deficiency is a rare cause of ED Testosterone deficiency is a rare cause of ED Administered orally, i/m injections, skin patches or implants Administered orally, i/m injections, skin patches or implants


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