Erectile Dysfunction Steven Lun The Townsville Hospital JCU Mater Pimlico / Womens & Childrens Ferring Australia Honary Board Member

Learning Objectives On completion of this educational activity , participants should be better able to Evaluate specific needs of patients & their expectations of ED treatment Be able to take a sexual history Implement ED treatment strategies

Erectile Dysfunction Common Problem Inability to maintain an erection firm enough to have sexual intercourse 10 % Male population 30 million American men

Erectile Dysfunction Significantly associated with Increased age Diabetes Cardivascular Disease Hypertension Depression Smoking Medications Multifactorial etiology with physical and psychological factors

The Past Pre 1980 Pyschogenic Problem

The Past 1960 ‘s 1970 ‘s 1980 ‘s - Understanding early surgery Pumps implants 1980 ‘s - Understanding Injections 1983 Brindley

Role of NO & cGMP NO is released cGMP formed Flaccidity Guanylate Cyclase Erection Nitric Oxide NO is released cGMP formed Lower intracellular calcium Penile smooth muscle relaxation And increased blood flow leads to Erection PDE5 terminates NO/cGMP signaling leading to flaccidity GTP 5’-GMP PDE5 cGMP

NO Receptor Diseases with abnormal NO Production Hypertension Obesity Dyslipidemias Diabetes I and II Heart Failure Atherosclerosis Aging Cigarette smoking

1980-90’s Andrology IIEF International Index Erectile function Sep Shim EHS Sear Pairs Edits QEQ Sex Q NTP tests Dynamic cavernosography Hormonal Testing

1990’s Vascular Agents Phosphodiesterase Inhibitors Prostaglandin Sildenafil Viagra Vardenifil Levitra Tadenafil Cialis Prostaglandin Alprostadil Caverjet

The Present Patients are in the drivers seat Trial PDE5 inhibitor Intracavernosal therapy Referral

The Future Newer agents Avanafil Post Radical Prostatectomy Diabetes Acts 15 min No effect with food

Urologists Assess Investigate Appropriate option

Vacuum Device Externally applied device mechanically effects penile blood engorgement Cylinder/pump placed over penis creates closed chamber; pump creates vacuum, drawing blood into corpora cavernosa Constrictive elastic ring then placed at base of penis to restrict flow of suctioned blood

Vacuum Device Some Advantages Some Disadvantages Non-invasive Drug free Cost effective Some Disadvantages Cumbersome Unnatural erection Erection is not warm to the touch Bruising/burst blood vessels Penile pain/discomfort Numbness Delayed ejaculation

Intracorporeal Injection Therapy A small needle is used to inject medication directly into the penis. The medication allows blood to flow into the penis creating an erection. Some Advantages Effective erection On-set of erection within 5 to 20 minutes

Intracorporeal Injection Therapy Some Disadvantages Risk of erection lasting 4 hours or more (priapism) Fear of sticking needle in penis Possible bleeding at injection site Requires training Possible pain at injection site Cavernosal fibrosis Poor long-term tolerability

Penile Implants An Option For men who have tried other option without success 40 year history High patient and partner satisfaction

Satisfaction Rates Overall Patient Satisfaction with ED Treatment

Types Penile Prosthesis One-Piece Non-Inflatable Two-Piece Inflatable Three-Piece Inflatable

Three Piece Prosthesis Some Advantages Totally concealed in body Device is inflated to provide rigidity and deflated for concealment Erection longevity is controllable When deflated, the cylinders are soft and flaccid Expands in girth (all AMS 700® cylinders) and length (AMS 700 LGX ® and Ultrex ® cylinders)

Possible Risks Will make latent natural or spontaneous erections as well as other interventional treatment options impossible If an infection occurs, the prosthesis may have to be removed May cause the penis to become shorter, curved or scarred There may be mechanical failures of the prosthesis Urogenital pain (typically associated with healing process )

How Well Are We Doing Not that great

Physician trends Prescriptions for ED Constant 2007-10 Primary Care Physicians prescribe majority Medicines followed by Urologists Urologists Start twice as many new prescriptions

What Are Patients Looking For PDE5 I – 50 % dissatisfied Cost Product performance Spontaneity

What Are Patients Looking For Preferences depend on Age Duration ED Prior Rx Experience Sexual Dynamics 70- 40 vs 70 -70 Dynamics and frequency sexual relationships Side effects Duration of Action Consistency of response Partner satisfaction

An Uncomfortable Situation

Has Your Doctor Asked Whether You Have Sexual Difficulties?

Barriers to Discussing ED Physician Discomfort Lack of Knowledge Personal Bias Time constraints Patient Embarrassment Shame Ignorance re normal Cultural beliefs Religious beliefs

Impact Of Physician Questioning On Patient Report Of Sexual Complaints Spontaneous reporting ~ 14% Reporting after Direct Questioning ~ 55%

Why Take A Sexual History Sexual problems may be the harbinger of underlying disease Sexual health is an Unalienable right of every patient Has the potential to improve patient – physician relationship Sexual problems are eminently treatable Important part of setting realistic expectations

Principles for Sexual History Taking Patients prefer clinician to Initiate Adjust language to the individual patient Assure confidentiality Empathetic & normalizing statements Demonstrate lack of embarrassment Cultural Sensitivity Avoid judgement statements & assumptions Avoid ageism Ask the partner if present

Sexual Problem Assessment Phases Affected – Tumescence Ejaculation Orgasm Lifelong vs acquired ( timeline ) Generalized vs situational Sudden vs gradual Distress = Bother Partner based vs self stimulation Rigidity Sustaining capability Nocturnal erections

Screening for Sexual Dysfunction Open ended Style questions “Men with diabetes often suffer from ED” “Are you having any problems with ? “ “Tell me more “ “What do you mean by that “

Take Home Messages Sexual history taking is important Sexual history is not an innate skill Training in this area needs improvement Basic Principles are worth following Practice and comfort development are essential Appropriately taken history can impact upon Patient diagnosis Patient decision making Patient satisfaction

Case 1 52 Yr old male executive Enquiring re Vasectomy Complains of ED BMI 26 Medications Atenolol Nexium What Questions would you ask and would you investigate?

Case 2 48 Yr Aircraft maintenance Fitter Complains Impotence 5 years F 111 Reseal Deseal exposure Complains Impotence 5 years Unable to initiate Tumesence Has Tried Viagra – no benefit Parathesia of feet What questions and investigations would you ask for

Case 3 62 Yr old male 75 kg Ex Medical Rep wishing for Cure of his ED 40 year smoker PSA 8 CaP Gleason 7 – Radical Prostatectomy 2 yr previous No Medications Cialis of no benefit What Questions would you ask Any Investigations you would do ?

Case 4 48 Yr Salesman c/o Impotence 5 Years Can initiate Tumesence but soft and premature detumescence Has tried viagra ,Mens Clinic to no avail Wife accusing him of playing around threatening to leave No medications What Questions and Investigations would you ask ?