1. Consultation with the Erectile Deficient Patient
Jeffrey M. Spier, M.D.
Scripps Mercy Hospital &
Pomerado Hospital
Department of Urology

2. What constitutes an Erection ?

3. BRAIN CENTERS INVOLVED IN SEXUAL FUNCTION
Level
Region
Function
Forebrain
Hypothalams
Brain Stem
Midbrain
Medial amygdala
Stria terminalis
Pyriform cortex
Hippocampus
Right insula and inferior frontal cortex
Left anterior cingulate cortex
Medial preoptic area
Paraventricular nucleus
Nucleus paragigantocellularis
A5 catecholamine cell group, locus coeruleus
Periaqueductal gray
Controls sexual motivation
Inhibits sexual drive (hypersexuality when destroyed)
Involved in penile erection
Increased activity during visually evoked sexual stimulation (sexual arousal)
Ability to recognize a sexual partner, integration of hormonal and sensory cues
Facilitates penile erection (via oxytocin neurons to lumbosacral spinal autonomic and somatic efferents)
Inhibits penile erection (via serotonin neurons to lumbosacral spinal neurons and interneurons)
Noradrenergic innervation of anterior horn motor neurons to perineal striated muscles
Relay center for sexually relevant stimuli

4. Male Genital Anatomy
Two paired corpora cavernosa (erectile bodies) and a single corpus spongiosum surrounding the urethra, all encased within Buck’s fascia
The erectile tissue is comprised of a network of vascular sinusoids surrounded by trabecular smooth muscle.

5. Vascular Supply
The blood supply to the penis is derived from the pudendal artery which branches from the internal iliac (hypogastric) artery.
Cavernosal arteries course through the center of each corporal body and give rise to multiple helicine arteries which open into the lacunar spaces.

6. Mechanism of Erection
Two types of erections – a) Reflexogenic b) Psychogenic
Blood flow increases secondary to vasodilatation of the cavernosal arteries
Relaxation of smooth muscle dilates the lacunar spaces causing engorgement
Increased intracorporal pressure expands the trabecular wall against the tunica albuginea
Compression of the subtunical veins along with a reduction of venous blood flow results in elevated pressures in the lacunar spaces, “veno-occlusive” mechanism
Flaccid penis - arterial pressure 20mm/Hg
Fully erect - arterial pressure mm/Hg

7. Neuroanatomy
The parasympathetic nervous system provides excitatory input causing vasodilation and erection. (autonomic)
The sympathetic nervous system provides input which results in detumescence, maintains flaccidity,and emission. (autonomic)
Somatic sensory nerves provide sensation of the penile skin, glans, and urethra. (dorsal nerve). The motor pathway lies within the sacral nerves to the pudendal nerve and innervate the bulbocavernous and ischiocavernous muscles and allow for ejaculation.

8. Neurovascular Bundle

9. Putting it all together

10. Biologic Erections - Adults
Men have 4-5 nocturnal erections
“Maintenance erections”
Each lasting approximately 10 minutes
Typically testosterone dependent
Can be a useful marker to determine psychological vs. organic ED
But not a replacement for actual sexual activity.

11. “ The Penis does not obey the order of its master, who tries to erect or shrink it at will. Instead, the penis erects freely while its master is asleep…….The penis must be said to have its own mind, by any stretch of the imagination.” Leonardo Da Vinci (1504)

12. Erectile Dysfunction
Defined as the inability to maintain or achieve an erection for satisfactory sexual intercourse.
May include physiologic, organic, or mixed causes
Prevalence of Erectile Dysfunction among men yrs is approximately 52% (minimal 17.2%, moderate 25.2%, and complete 9.6%)
Probability of Erectile Dysfunction increases with age – and typically associated with other medical conditions

13. Massachusetts Male Aging Study:
Feldman HA, et al. J Urol. 1994;151:54-61.

14. Physiological Causes of Erectile Dysfunction
Hypertension
Depression
PVD
Anemia
Drug abuse
Vascular surgery
CAD
Endothelial dysfunction ED
Hypogonadism
Smoking
Alcohol abuse
Peyronie’s disease
Trauma/surgery to
pelvis or spine
Endocrine Disorders
Hyperlipidemia
Benet AE, Melman A. Urol Clin North Am. 1995;22:

15. Physiologic Indicators of ED
Atherosclerosis in narrow penile arteries may manifest as ED before becoming apparent in other arteries.
Slide 3 Indicators of ED
Patients you see every day—including men with hypertension, diabetes, or hyperlipidemia—may have ED.5-7 Atherosclerosis in narrow penile arteries may manifest as ED before it becomes apparent in other arteries. Detecting atherosclerosis in 1 set of blood vessels increases the chance of finding it in other vessels.
Detecting atherosclerosis in 1 set of blood vessels increases the chance of finding it in other vessels.

16. Risk Factors: Similar between Heart Disease and Erectile Dysfunction
Risk factors very similar
smoking
dyslipidemia
hypertension
diabetes
obesity
lack of exercise/sex
Both are vascular conditions

17. Medications Associated With ED
Estrogens
Antiandrogens
H2-receptor blockers
Anticholinergics
Ketoconazole
Marijuana
Alcohol
Antihypertensives
Narcotics
ß-blockers
Psychotropics
Cigarettes
Cocaine
Spironolactone
Lipid-lowering agents
NSAID’s
Cytotoxic drugs
Diuretics
Benet AE, Melman A. Urol Clin North Am. 1995;22:

19. Risk Factors for ED

20. Normal Physiology

21. Link Between LUTS and ED

22. Smooth Muscle Dysfunction: Common in LUTS and ED

23. Psychogenic vs Organic
Tiefer L, Schuetz-Mueller D. Urol Clin North Am. 1995;22:

24. Signs and Symptoms Suggestive of Psychogenic vs Organic ED
Sudden onset
Gradual onset
Complete immediate loss
Incremental progression
AM erections present
Lack of AM erections
Varies with partner and circumstance
Lack of erections under most sexually stimulating circumstances
Adapted from Ralph D, et al. BMJ. 2000;321:

25. Patients Who Ask,…
Should we believe a 35 year old that c/o erectile dysfunction? Yes, evaluation should be part of any genitourinary history and physical
Remember ED (endothelial dysfunction) or EQ (erectile quality) = Erectile Dysfunction
What is the role of individual sexual habits?
Don’t treat the age - “Treat the individual”

26. Case History
45 year old white male presents with complaints of erectile dysfunction

27. Obtain History When did the problem begin?
Does he have normal sexual desire?
What kind of relationship with partner? (any extramarital relationships)
Does he have spontaneous erections?
Any recent stress at home or work?
Any past pelvic or lower back surgeries?
Voiding difficulties, hematuria, dysuria, or incontinence?
What type of treatments in the past?
AUA voiding score or recent PSA?

28. Evaluation Detail History and Physical
Targeted medical, sexual, and psychosocial history
Physical exam of genitalia
Secondary sexual characteristics
Check for penile abnormalities
Check for groin and peripheral pulses
Routine laboratory :
screening for diabetes, liver disease, or renal disease, testosterone (prolactin level if testosterone low) Fasting lipids, glucose, and androgens
Specialized testing:
Nocturnal Penile Tumescence (NPT can differentiate b/w psychogenic vs organic ED ) Color Doppler imaging ( minimally invasive way to identify vascular ED)

30. Sexual Health Inventory for Men
5-Item questionnaire:
Erection confidence
Erection firmness
Maintain erection
Maintain to completion
Intercourse satisfaction
SHIM Score Correlates ED Severity
Normal erectile function
Mild ED
Mild-to-moderate ED
Moderate ED
 Severe ED
Rosen RC, et al. Int J Impot Res. 1999;11:

32. Treatment of Erectile Dysfunction
Non – Invasive Therapy:
Psychotherapy
Oral PDE-5 Inhibitors
Vacuum Erection device
Testosterone supplementation
Invasive Therapy:
M.U.S.E (meatal urethral suppository for erection)
Alprostadil cavernosal injection
Penile revascularization
Penile prosthesis – malleable or inflatable

33. Psychosocial Counseling : First-Line Therapy
Useful as monotherapy or as adjunctive treatment and may include:
Communication training for couples
Anxiety reduction/desensitization
Cognitive-behavioral interventions
Sexual stimulation techniques
Rosen RC. Urol Clin North Am. 2001;28:

34. Vacuum Erection Device
Cylindrical vacuum pump placed over the penis. Air is drawn from the cylinder, causing blood to flow into the penis
Occlusive ring is placed around the penile base to maintain the erection
Maximum duration of use: minutes
Complications include penile pain, penile bruising, hematoma

35. Testosterone Supplementation
Not indicated in men with normal testosterone levels
Indications include: libido, energy, muscle strength, erectile dysfunction, and osteoporosis
Literature now controversial in regards to testosterone supplemation in men with increased PSA and even diagnosed prostate cancer

36. Alprostadil Delivery

37. MUSE (Medicated Urethral System for Erection)
Erection begins 5-20 minutes after administration
Must use a condom barrier
Side effects: burning of genitals or urethra, urethral bleeding, priapism, hypotension

38. Intracavernosal Injections
Trimix/Bimix: refers to mixture containing 2 or 2 of the following agents: papaverine, phentolamine, alprostadil
Side effects: pain, penile fibrosis, priapism
Patient must be taught in office and observed when initiating treatment of either MUSE or injection therapy

39. Penile Prosthesis: Realistic Expectations ?

40. Placement of Penile Prosthesis

41. Type 5 Phosphodiesterase (PDE5) Inhibitors
Viagra (Sildenafil) Tabs: 25, 50, 100 mg.
Levitra (Vardenafil) Tabs: 2.5, 5, 10, 20 mg.
Cialis (Tadalafil) Tabs: 5, 10, 20 mg.

42. Clinical Benefits of PDE5 Inhibitor Therapy
Can be taken orally
Well tolerated by most patients
High success rate when used appropriately
Effects of drug are reversed once drug is discontinued
Results in natural erection
Long term data suggests certain class of medications can be used with continued success

44. Phosphodiesterase 5 Ihibitors
PDE 5 Inhibitors
Lowering of Ca++
Smooth muscle relaxation

46. PI Data: High Fat Meal
Viagra…when taken with a high fat meal, the rate of absorbtion is reduced, and mean delay in Tmax of 60 minutes
Levitra…as with Viagra, high fat meal affects absorbtion, 4 hour effect (same as Viagra)
Cialis – No effect on Cmax or Tmax, hour effect

47. PI Data: Side Effect Profile
Sildenafil
Headache 16%
Flushing 10%
Dyspepsia 7%
Nasal congestion 4%
Blue vision 3%
Vardenafil
Headache 15%
Flushing 11%
Dyspepsia 4%
Nasal congestion 9%
Blue vision <2%
Tadalafil
Headache 15%
Flushing 3%
Dyspepsia 10%
Nasal Congestion 3%
Back pain 6%
Myalgia 3%
Limb pain 3%

49. Excellent PDE5 Selectivity
PDE6—retina (1:10)
PDE1—vasculature, heart, brain (1:80)
PDE3—heart (1:4600)
PDE11—heart, pituitary, testes (1:780)
PDE5—penis (1:1)
Slide 49 Excellent PDE5 Selectivity
VIAGRA® (sildenafil citrate) is highly selective for PDE5, which is present in high concentrations in the smooth muscle of the penis.12,13
VIAGRA does not inhibit PDE11, and it has no effect on sperm motility or morphology.1
Please see accompanying full prescribing information for VIAGRA 25-mg, 50-mg, 100-mg tablets by clicking on the prescribing information button located on the main menu of this CD-ROM program.
Gbekor E, et al. Poster presented at: European Association of Urology; February 23-26, 2002; Birmingham, United Kingdom.

50. Myalgia and Back Pain Effects: Tadalafil
No CPK changes
No rhabdomyalgia
Recommended to take anti-inflammatory for those patients that c/o symptoms
Over 10% combined side effect
Leading cause of discontinuation

51. PI Data: Alpha-blocker Issue
Levitra:
contraindicated with ALL alpha-blockers
Tadalafil:
Previously contraindicated with ALL alpha-blockers except for 0.4mg dose of Flomax
Sildenafil:
Precaution only pertains to Doxazosin (Cardura) and Terazosin (Hytrin), not Tamsulosin (Flomax).
Viagra doses above 25 mg’s should not be taken within 4 hours of taking an alpha-blocker.
Recently the FDA removed any contraindication with PDE 5 inhibitors, however patients should be counseled on potential interactions

52. What do we know? Clinical Data: Sildenafil Vardenafil Tadalafil
> 7 years of clinical experience
Prescribed by more than 600,000 Physicians to >23,000,000 patients
More than 2000 published abstracts, papers, reviews, commentaries, and supplement papers
Vardenafil
Limited data to date on LONG term effectiveness, some QT interaction
Tadalafil
Limited data to date on LONG term effectiveness, very long half-life

53. Sildenafil Efficacy With Prolonged Duration of Therapy
Improved Erections (%)
Patients reporting
Weeks of Treatment n=
W Steers, et.al., Int Journ of Impotence Research. 2001;

54. Why Do Patients Discontinue PDE5 Inhibitors
Lack of adequate education and preparation
Unrealistic patient expectations
Partner’s resistance to medication
Safety concerns
Negative attitude
Prolonged sexual inactivity
Loss of desire for sex
E.D. unresponsive to oral medical therapy

55. Post Prostatectomy Erectile Dysfuntion
Potency results following radical retropubic prostatectomy with bilateral nerve sparing vary widely
At major centers with experienced surgeons the range is 40%-86%
Most urologists rarely report potency rates higher than 40%
Factors include age, pre surgical erectile function

56. Post Prostatectomy Erectile Dysfunction
Function of any smooth muscle is dependent on tissue oxygenation
Penile hypoxia is the key factor in collagen deposition
Nightime erections have been implicated in preserving normal erectile funtion by providing regular tissue oxygenation
The lack of any erections after nerve damage from surgery may be the cause of penile hypoxia and fibrosis formation

57. Post Prostatectomy Erectile Dysfunction
Nerve damage from radical retropubic prostatectomy may last up to a year
Robotic surgery and post operative potency results look incredibly promising

58. Robotic Operations Small incisions 3-D vision
Enhanced dexterity/no tremor
Instrument wrist motion
Comfortable position for surgeon

59. Da Vinci Robotic System

61. Post Prostatectomy Erectile Dysfunction Treatment Options
Pharmacologic Agents
Daily or days/month
PDE-5 inibitors
Injection therapy three times a week
Intraurethral alprostadil three times a week (MUSE)

62. Post Prostatectomy Erectile Dysfunction Treatment Options
Non-pharmacologic agents
Vacuum Erection device: daily for 5-10 minutes
Combination of above pharmacologic and non-pharmacologic treatments

63. Post Prostatectomy Erectile Dysfunction Treatment Options
Current literature recommends early penile rehabilatation with Vacuum Erection Device and PDE-5 inhibitors
Most user friendly, cost effective, and patient compliant

64. Thank you for attending
Jeffrey Spier M.D