1. John Ewan Sandyford Glasgow
Erectile Dysfunction
John Ewan
Sandyford
Glasgow

2. Overview Epidemiology Anatomy and Physiology History Examination
Investigations
Treatment

3. Definition of ED DSM-IV (American Psychiatric Association, 2000)
Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate erection
The disturbance causes marked distress or interpersonal difficulty
The erectile dysfunction is not better accounted for by another Axis I disorder (other than a sexual dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition

4. Epidemiology
Massachusetts Male Aging Study, Feldman et al. J Urol 1994; 150:54-61
Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 7

5. Anatomy and Physiology of erection
Reproduced from Carson C, Holmes S, Kirby R. Fast Facts- Erectile Dysfunction. Oxford: Health Press Limited; 2002: 8

6. Anatomy and Physiology of erection
Parasympathetic nerves S2-4 mediate erection
Sympathetic nerves T11-L2 control ejaculation and detumescence
Smooth muscle relaxation
Nitric oxide diffuses into cavernosal smooth muscle cells, activates Guanylate cyclase converts guanosine triphosphate to cGMP resulting in smooth muscle relaxation. Effect of cGMP stopped by Phosphodiesterase type 5 which exists primarily in corpora cavernosa.

7. Veno-occlusive Mechanism
Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 :12

8. History Detailed description of problem, is it ED? Causative factors
Sexual desire/libido
Ejaculatory disorders
Impact on quality of life and on relationship
Expectations of treatment

9. Clues differentiating psychogenic from organic causes
Sudden onset
Situational
Normal waking and nocturnal erections
Normal erection with masturbation
Relationship problems
Life event
Anxiety, fear, depression
Organic
Gradual onset
All situations
Reduced or absent waking and nocturnal erections
No erection with masturbation
Penile pain

10. Relationship issues Current relationship status Length of relationship
Previous sexual partners and relationships
Partner issues e.g. menopause/pain/cancer

11. History Medical Surgical Psychiatric Medication Smoking Alcohol
Recreational drug use

12. Arteriogenic Cause of ED
Hypertension
Smoking
Diabetes
Hyperlipidaemia
Peripheral vascular disease
Blunt perineal or pelvic trauma
Pelvic irradiation

13. Neurogenic causes of ED
Lesions of medial preoptic nucleus, paraventicular nucleus, hippocampus
Spinal trauma
Myelodisplasia (spina bifida)
Pelvic surgery/radiotherapy
Multiple sclerosis
Intervertebral disc lesion
Peripheral neuropathies
Alcohol
Diabetes
HIV

14. Psychogenic and Psychiatric causes
Anxiety
Loss of attraction to partner
Relationship difficulties
Stress
Depression

15. Psychogenic ED
Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 33

16. Endocrine causes of ED Hypogonadism Thyroid disease Low testosterone
Raised SHBG
Raised Prolactin
Thyroid disease

17. Drugs associated with ED
Antihypertensives
Thiazides
B blockers
Centrally acting drugs
Antidepressants
Tricyclics
MAO inhibitors
SSRI
Anticholinergics
Atropine
Antipsychotics
Phenothiazines
Anxiolytics
Benzodiazepines
Psychotropic drugs
Alcohol
Opiates
Amphetamines
Cocaine

18. Examination Blood pressure Peripheral pulses, palpate for AAA
Testes size and consistency
Secondary sexual characteristics
Penis for Peyronie’s plaques, phimosis

19. ED and Coronary Artery Disease
Generalised atherosclerosis
Penile arteries smaller than coronary arteries
ED pre-dates coronary artery disease
Man with ED and no cardiac symptoms is a cardiac patient until proven otherwise

20. Investigations Fasting glucose and lipids
Morning testosterone and SHBG
If testosterone is low or borderline repeat with Prolactin, FSH and LH
Thyroid function
PSA

21. Specialised Investigations
Vascular studies
Young patients with primary ED
History of trauma e.g. penile fracture
Patients unresponsive to medical therapies

22. Treatment of ED General Measures
Smoking cessation
Reduce alcohol
Weight loss
Exercise

23. Endocrine Disorders Hypogonadism Hyperthyroidism Hyperprolactinaemia
Endocrinology referral

24. Psychosexual therapy
Even if cause of ED is physical the patient will develop psychosexual issues
Performance anxiety
Sensate focus exercises
Relationship counselling

25. Drugs for ED Oral agents Intra-cavernosal Intra-urethral
Centrally acting dopamine-receptor agonist Apomorphine (discontinued in UK)
Phosphodiesterase type 5 inhibitors
Intra-cavernosal
Prostaglandin E1 Alprostadil
Intra-urethral
Alprostadil

26. PDE5 inhibitors Sildenafil (Viagra) 25mg, 50mg, 100mg
1 hour before sexual activity
4-6 hour window
Absorption delayed by fatty meal
Tadalafil (Cialis) 10mg, 20mg
30 minutes before sexual activity
36 hour window
Absorption not affected by food
Tadalafil (Cialis) 5mg
daily
Vardenafil (Levitra) 5mg, 10mg, 20mg
30-60 minutes before sexual activity
Absorption delayed by fatty meal

27. PDE5 Physiology
Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 40

28. PDE5 Inhibitors Side Effects
Facial flushing
Headache
Nasal congestion
Dizziness
Dyspepsia
Visual disturbance (blue halo)
Priapism
Non-arteritic anterior ischaemic optic neuropathy

29. PDE5 Contraindications
Recent cardiovascular event
Nitrates
Hypotension
Anatomical deformity
Angulation, cavernosal fibrosis, Peyronie’s
Predisposition to prolonged erection
Sickle cell disease
Multiple myeloma
Leukaemia

30. PDE5 Drug Interactions Nitrates Cytochrome P450 inhibitors
Glyceryl trinitrate, isosorbide mono or dinitrate
Chest pain after taking Sildenafil/Vardenafil no nitrates 24 hours, Tadalafil no nitrates 48 hours
Recreational amyl nitrate (Poppers)
Cytochrome P450 inhibitors
Protease inhibitors especially Ritonavir use very small dose
Cimetidine, Ketoconazole, Erythromycin
Alpha blockers

31. Intracavernosal Injections
Alprostadil (Caverject, Viridal) 5-40 mcg
Independent of intact nervous system
Manual dexterity, adequate vision, training
Contraindicated: bleeding disorders, sickle cell anaemia, multiple myeloma, leukaemia
Side effects: penoscrotal pain, haematoma, fibrosis at injection sites, priapism
Papaverine, Phentolamine, Aviptadil (vaso-intestinal peptide) been used sole or with Alprostadil

32. Intracavernosal Injections
Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 53

33. Intraurethral Alprostadil (Muse) 125mg, 250mg, 500mg,1g
Pellet inserted with applicator
Massage penis to aid absorption
Side effects: Penile pain, dizziness, priapism rare

34. Intraurethral Alprostadil
Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 55

35. Vacuum Devices
Blood trapped in intracorporal and extracorporal compartments of penis
Constricting ring at base of penis
Cyanosis, oedema, cold
Pivots at base below ring
Maximum time 30 minutes

36. Vacuum devices
Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 61

37. Penile Prostheses Semi-rigid rods 2 piece inflatable prosthesis
3 piece inflatable prosthesis with abdominal reservoir
Risks
Infection
Destroys corpora cavernosa
Erosion and extrusion
Mechanical failure

38. Penile Prosthesis
Reproduced from Carson C,Holmes S,Kirby R. Fast Facts-Erectile Dysfunction. Oxford: Health Press Limited; 2002 : 66

39. NHS Prescription for ED
Diabetes
Multiple sclerosis
Parkinson’s Disease
Poliomyelitis
Prostate cancer
Prostatectomy incl TRP
Radical pelvic surgery
Severe pelvic injury
Renal failure
On dialysis
Transplant
Single gene neurological disease
Spinal cord injury
Spina bifida
Receiving NHS Rx 14/9/1998
Severe distress

40. Private Prescription Pharmacy costs vary Sildenafil 100mgX4 £25-£40
Pharmacy2U £25

41. Conclusions ED is a common problem Impact on patient and partner/s
Overlap of psychological and physical
May be initial presentation of diabetes or coronary artery disease
Good range of safe and effective therapies
If YOU don’t ask your patient may be too embarrassed to tell you