1. Erectile Dysfunction Also Known as Impotence

2. Overview
Erectile dysfunction (ED) is the inability of a man to achieve or maintain an erection sufficient for his sexual needs or the needs of his partner. Most men experience this at some point in their lives, usually by age 40, and are not psychologically affected by it.

3. Overview
Some men, however, experience chronic, complete erectile dysfunction (impotence), and others, partial or brief erections. Frequent erectile dysfunction can cause emotional and relationship problems, and often leads to diminished self-esteem. Erectile dysfunction has many causes, most of which are treatable, and is not an inevitable consequence of aging.

4. Is this really an Important Problem?
18 million men aged 40 to 70 years will have experienced erectile dysfunction at some point in their life.
If you include partial erectile dysfunction, that number increases to 30 million men.
That number is suppose to increase to > 300 million by 2025.
In a study, where the average of the person was 70 years old, the percent of ED was 34%
In the Baltimore Aging Study, the prevalence of ED was 75% in patients 80 years and older.
(Urol Clin of NA, 1999)
(Urology Aug 2002)
(Am Fam Phys 2000).

7. Effects of ED on Self Esteem
Because sexual performance is often a big part of a man's self-esteem, experiencing ED can be devastating not only to a man's sex life, but to his entire sense of being. Men with ED can become uncertain of themselves and avoid intimate situations with their partners; this only increases the pressure and anxiety associated with a condition which is often treatable.

8. Effects of ED on Self Esteem
In addition, erectile dysfunction can cause men to feel inadequate in their roles. Men who are suffering from ED tend to isolate themselves from their relationships and withdraw from their partners.

9. Effects of ED on Self Esteem
The psychological effects of ED can invade every aspect of a man's life, from his relationship with his partner, to his interactions on a social level, to his job performance.

10. Effects of ED on Self Esteem
Therefore, it is important for a man who is suffering from ED to feel as comfortable as possible discussing his condition with his partner, and with his physician, in order to discover the treatment strategy which can best help overcome this condition.

11. Physiology of Erection
The physiological process of erection begins in the brain and involves the nervous and vascular systems. Neurotransmitters in the brain (e.g., epinephrine, acetylcholine, nitric oxide) are some of the chemicals that initiate it. Physical or psychological stimulation (arousal) causes nerves to send messages to the vascular system, which results in significant blood flow to the penis.

12. Physiology of Erection
Two arteries in the penis supply blood to erectile tissue and the corpora cavernosa, which become engorged and expand as a result of increased blood flow and pressure.

13. Physiology of Erection
Because blood must stay in the penis to maintain rigidity, erectile tissue is enclosed by fibrous elastic sheathes (tunicae) that cinch to prevent blood from leaving the penis during erection. When stimulation ends, or following ejaculation, pressure in the penis decreases, blood is released, and the penis resumes its normal shape.

14. Physiology
Erectile Dysfunction is essentially a vascular disease. It is often associated with other vascular diseases and conditions such as diabetes, hypertension, and coronary artery disease. Other conditions associated with ED include neurologic disorders, endocrinopathies, benign prostatic hyperplasia, and depression.

15. Why do Geriatric Patients get ED?
Atherosclerotic disease accounts for almost 50% of the ED in men>60 years old.
In geriatric patients, 70 years or older, who had diabetes, over 90% of patients experienced ED.
In a study with patients with hypertension, the prevalence was 68.3% that had some degree of ED.
(Am J of Cardiology 2003)
(Clin Ger Medicine 2003)
(Am J of Card 2000)

16. Causes of ED
There are many underlying physical and psychological causes of erectile dysfunction. Reduced blood flow to the penis and nerve damage are the most common physical causes. Underlying conditions associated with erectile dysfunction include the following:

17. Causes: Vascular Disease
Vascular Disease is the most common cause of ED
Arteriosclerosis, the hardening and narrowing of the arteries, causes a reduction in blood flow throughout the body and can lead to impotence. It is associated with age and accounts for 50% to 60% of impotence in men over 60.
NOTE: ED may be the initial sign preceding an MI or a stroke.

18. Causes: Vascular Disease
Risk factors for arteriosclerosis include:
Diabetes mellitus
High blood pressure
High cholesterol
Smoking, which can lead to any of the above risk factors, is perhaps the most significant risk factor for impotence related to arteriosclerosis.

19. Causes: Diabetes Mellitus
Diabetes Mellitus Chronic high levels of blood sugar associated with diabetes mellitus often damage small blood vessels and nerves throughout the body, which can impair nerve impulses and blood flow necessary for erection. About 60% of men with diabetes experience impotence.

20. Causes: Drugs
Drugs Over 200 commonly prescribed drugs are known to cause or contribute to impotence, including drugs for high blood pressure, heart medications, antidepressants, tranquilizers, and sedatives. A number of over-the-counter medications also can lead to impotence..

21. Causes: Drugs
Long-term use of alcohol and illicit drugs may affect the vascular and nervous systems and are associated with erectile dysfunction

22. Causes: Hormone Imbalances
Hormone Imbalances Hormone disorders account for fewer than 5% of cases of impotence. Testosterone deficiency, which occurs rarely, can result in a loss of libido (sexual desire) and loss of erection.

23. Causes: Hormone Imbalances
Among other conditions, an excess of the hormone prolactin, caused by pituitary gland tumor, reduces levels of testosterone. Hormone imbalances can also result from kidney or liver disease.

24. Causes: Neurologic Conditions
Neurologic Conditions Spinal cord and brain injuries (e.g., paraplegia, stroke) can cause impotence when they interrupt the transfer of nerve impulses from the brain to the penis. Other nerve disorders, such as multiple sclerosis (MS), Parkinson's disease, and Alzheimer's disease, may also result in impotence.

25. Pelvic Trauma, Surgery, Radiation Therapy
Trauma to the pelvic region or spinal cord can damage veins and nerves needed for erection. Surgery of the colon, prostate, bladder, or rectum may damage the nerves and blood vessels involved in erection.

26. Pelvic Trauma, Surgery, Radiation Therapy
Prostate and bladder cancer surgery often require removing tissue and nerves surrounding a tumor, which increases the risk for impotence.

27. Pelvic Trauma, Surgery, Radiation Therapy
New nerve-sparing techniques aimed at lowering the incidence of impotence to 40% to 60% are now being developed and used in these surgeries. Temporary impotence is also associated with these procedures, even those in which nerve-sparing techniques were used. It can take as long as 6 to 18 months for full erections to return.

28. Pelvic Trauma, Surgery, Radiation Therapy
Radical cystectomy (for bladder cancer) and prostatectomy (for prostate cancer) require cutting or removing nerves that control penile blood flow. These nerves do not control sensation in the penis and are not responsible for orgasms; only erection is affected by these procedures.

29. Pelvic Trauma, Surgery, Radiation Therapy
Radiation therapy for prostate or bladder cancer also can permanently damage these nerves.

30. Causes: Peyronie’s Disease
Peyronie's disease is a rare inflammatory condition that causes scarring of erectile tissue. Scarring produces curvature of the penis that can interfere with sexual function and cause painful erections.

31. Causes: Psychological Conditions
Psychological Conditions Depression, guilt, worry, stress, and anxiety all contribute to loss of libido and erectile dysfunction. If a man experiences loss of erection, he may worry that it will happen again.

32. Causes: Psychological Conditions
This can produce anxiety associated with performance and may lead to chronic problems during sex. If the cycle is inescapable, it can result in impotence. Psychological factors in impotence are often secondary to physical causes, and they magnify their significance.

33. What are Doctors Doing About It?
Despite a general belief that older patients are “not interested in sex” or have “decreased libido”, a survey of 1202 men aged 58-94, showed that 70% were interested in sexual behavior and 67% thought satisfying sex was an important aspect of life.
However, only 33% of patients who experience ED reported the problem to a physician.
A study of patients with ED found that only 10% of doctors discussed this problem
(J of Gerontology 1999)
(Am J of Cardiololgy 2000).

34. Treatments Non-pharmacological Treatments Pharmacological Treatments
Vacuum Pump
Intracavernosal injections
Psychological therapy
Implants (last treatment of choice)
Pharmacological Treatments
Viagra (Sildenafil)
Levitra (Vardenafil)
Cialis (Tadalafil)

35. Siladenafil (Viagra)
Sildenafil is by far the most extensively studied PDE5 inhibitor.
Over 20 million men worldwide has used sildenafil in 110 countries.
Over 1000 studies have been done with sildenafil.
Typical dosage is 50mg 1 hour before sexual activity, although 25mg can be used in elderly.
Most common side effect is HA, flushing, dyspepsia.
The only contraindication with Viagra is concommitant use with nitrates.
There is a slight hypotensive effect of 5-10mmHg in normotensive patients.

36. Levitra (Vardenafil)
Vardenafil is a selective PDE5 inhibitor, with a maximal concentration at approximately 60 minutes.
Dosages are typically 10mg to 20mg, but in the elderly, can consider 5 mg.
Has all the same similar side effects and contraindications as Viagra, AND . . .
Because it is metabolized by liver, should not be used with erythromycin or HIV meds.
Because of its hypotensive effect, it is contraindicated with alpha-blockers. One study showed 6 out of 8 pts had SBP <85 mmHg after taking 10mg of vardenafil and 10 mg of terazosin.

37. Cialis (Tadalafil)
Tadalafil is a new potent, highly selective reversible inhibitor of PDE5.
Tadalafil has a maximum plasma concentration at 2.0 hours, and an elimination half-life of 17.5 hours.
Dosing is typically mg, but studies have been done up to 100mg.
Like vardenafil, tadalafil is contraindicated with nitrates, pts with retinitis pigmentosa, and alpha-blockers except Flomax 0.4mg.
Other side effects besides HA, flushing, and rhinitis, include myalgia and back pain.
Pts with CRI or liver impairment, max dose is 10mg.