Presentation on theme: "Tom Havard 2013 Great Western Hospital GPST Teaching"— Presentation transcript:
1 Tom Havard 2013 Great Western Hospital GPST Teaching Erectile DysfunctionTom Havard2013Great Western HospitalGPST Teaching
2 History Impotentia coeundi 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 Sade1200s: Witchcraft1873: First surgical treatment, blocking veins.
10 Treatment Dependent on cause Psychological therapy to reduce anxiety, involving partnerLifestyle 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, mixedwith illicit drugs (beware amyl nitrate),cut flowers.
12 Eligible on NHS Diabetes MS Parkinsons Poliomyelitis Prostate Ca Prostatectomy incl TURPRadical pelvic surgeryRenal failure treated bydialysis or transplantSevere pelvic injurySingle gene neurological diseaseSpinal cord injurySpina bifidaReceiving Tx 14/09/98Impotence causing severe distress (after hospital assessment)One a week is appropriate, prescribers discretion to choose to give more
13 Contraindications Organic nitrates Hypotension <90/50. Careful use with alpha blockersSevere hepatic impairmentHereditary degenerative retinal disorders eg retinitis pigmentosaRecent stroke or MICareful use with otherP450 inhibitors egcimetidine
14 Sublingual Apomorphine Dopamine agonistNot as effective as SildenafilOnly licensed oral drug not absolutely contraindicated for use with nitratesPositive response in 40-50% patients
15 Intracavernosal Injections Alprostadil, Prostaglandin E1 causes vasodilationEffective in up to 80%Few contraindications or interactionsRequires training, manual dexterity,eyesightPain on injectionAlso used to maintain patentductus arteriosus
16 Transurethral Alprostadil Effective in 10mins, lasts 20-60minsLess effective than intracavernosal and slower acting, but less incidence of priapism
17 Vacuum DevicesPlastic cylinder, vacuum created by hand or electric pumpConstriction ring around base of penisReported long term success in up to60% of patients
18 Penile Prostheses Two types Malleable pair of rods with metal core Inflatable cylinders with internalpump and reservoirFor patients that have failed torespond to other treatments or havedeveloped fibrosisRisk of infection, erosion through theglans
19 Clinical Evidence Review Evidence of benefit:Alprostadil (both intracavernosal and transurethral), Apomorphine, Sildenafil, Tadalafil, VardenafilLikely to be beneficial:Ginseng, prosthesis, psychosexual counselling, vacuum devices, yohimbe bark
20 Referral From Primary Care UrologyYoung men that have always had difficultyHx of trauma (genitals, pelvis, spine)Clinical abnormality (micropenis, peyronies)Fail to respond to at least 2 max dose PDE5 InhibitorsEndocrinologyHypogonadism, abnormal testosterone,prolactinCardiologyDisease making sex or PDE5 use unsafePsychologists
21 Summary Common – 52% aged 40-70 Multiple causes Take comprehensive historyInvestigate cardiovascular diseaseConsider psychological managementMultiple treatments – First line SildenafilCheck if qualifies for NHS treatment and contraindicationsRefer as approprtiate