1. Erectile dysfunction The ins and outs Louise MacPherson

2. Definition: Gradual onset of inability to achieve an erection sufficient for penetration Most men have difficulty having an erection from time to time: stress, tiredness, alcohol, ‘not in the mood’. If persistent and prevents normal sex life, disrupting relationship, depressed > medical advice Not ejaculation problems, priapism

3. How common is it? Increased awareness, also strong media messages ‘what is normal’, marketing and availability Viagra > common but incorrect usage 1/3 ♂ over 50 yrs old, 52% some difficulty, 10% with complete ED Age variable most strongly associated with ED. Ageing population increasing problem Risk factors: age, smoking and obesity Increase prevalence due to: DM, HTN, CVD, Anxiety + Depression

4. Aetiology Multifactor, 80% organic cause Vascular: - uncontrolled DM, cardiac, vascular disease - new or complicated anti-HTN Rx Neurogenic: - Spinal cord injury - Neurological disease (e.g. MS) Hormonal: - ↓ testosterone, ↑ prolactin - TSH (rare cause hypothyroid) Organic (focal): - BPH - liver/kidney disease

5. Aetiology contd. Anatomical: excessive curvature (Peyronies Disease) Psychogenic: - normal libido, sexual identity, recent life stresses, chronic EtOH - not hormonal Medication: antidepressants, antihypertensives (ACE inhib + b-blocker)

6. History, examination and investigation History: IIEF-5 erectile dysfunction survey - (erection but unable maintain, nocturnal erections, libido) Review medication Basic explanation physiology erection BP Reflexes/Basic Neurological exam Scrotum/penis Urine sample (protein, glucose) Bloods: testosterone,prolactin, glucose, cholesterol, TSH PSA

7. Treatment or referral Self help: ↓ Etoh ↓ smoking ↓stress ↓weight Talking therapies Medication: 3 phosphodiesterase-5 (PDE-5) inhibitors. Only NHS if specific medical condition or severe distress Physical: vacuum device, rods and tubes topical meds: alprostadil, papaverine Referral: urology, neurology, endocrinology, counselling. Urology if PDE-5 failure (ineffective after 3 doses), anatomical, or Hx/exam suggests primary ED

8. PDE-5 inhibitors Sildenafil (Viagra) Tadalafil (Cialis) Vardenafil (Levitra) Contraindicated: low BP, Nitrates, multidrug anti-HTN medication, allergies BMJ clinical review (2006): - 1 systematic 1 subsequent RCT. Vardenafil 5,10,20 mg 1 hour before sex - ↑ rate successful intercourse measured by IIEF over 12/52. 20mg better than 10mg but ↑ S/E -S/E ⅓ : headache, flushing, rhinitis, dyspepsia

9.  Specialists: cavernosomotry, U/S penis, arteriogram

10. Resources www.emedicine/com/med/topic3023.htmwww.emedicine/com/med/topic3023.htm (detailed physiology and medication) www.bigonerectilehealth.comwww.bigonerectilehealth.com (for IIEF-5 erectile function questionnaire)