1. Tom Havard 2013 Great Western Hospital GPST Teaching
Erectile Dysfunction
Tom Havard
2013
Great Western Hospital
GPST Teaching

2. History Impotentia coeundi
Chinese 2500BC: Yin-Yang, herbs, acupuncture.
Egyptians 1600BC: Ground crocodile hearts, lotus flowers aphrodisiac (apomorphine)
300BC-1800s: Spanish Fly (cantharidin). Augustus Caesar, Henry IV, Marquis De Sade
1200s: Witchcraft
1873: First surgical treatment, blocking veins.

3. History
1918: Implanting monkey testicle, then cadavers, goats, boars, deer.
Early 20th Century: Electric shock treatment.
1935 Holland: Discover Testosterone.
1960s: Penile implants
1970s: Penis pumps
1980s: Injections
1994: Viagra

4. Erectile Dysfunction
Inability to initiate or maintain an erection to ejaculation.
Erection: in tact parasympathetic reflex S2, S3.
Ejaculation: in tact sympathetic L1 root.

5. Aetiology Blood Supply Hormones Nerves Psychological Hormones
70%

6. Aetiology Spinal cord or cauda equina Stroke PD MS
Traumatic nerve/vascular damage: eg radical prostatectomy, pelvic #
HTN,
SSRIs, antihypertensives
Smoking
Leriche Syndrome
Hypogonadism
Peyronies
Diabetes
Depression, anxiety, stress
Cycling

7. Epidemiology Affects 52% aged 40-70 10% complete ED 70% age >70yrs
Those with ED twice as likely to have MI, 20% higher chance of admission with heart failure, 10% more likely to have stroke

8. History When, How… Early morning erections
Anxieties about sexual matters
Organic causes
Diabetes, EtOH, Drugs,
Relationships, conflicts, communication
Depression

9. Investigations Bloods Glucose Testosterone, Prolactin TFTs Lipids
Routine

10. Treatment Dependent on cause
Psychological therapy to reduce anxiety, involving partner
Lifestyle change shows improvement in sexual function in one third of obese men

11. Drugs PDE5 Inhibitors thus increasing cGMP and interaction with NO
Sildenafil (Viagra)
Tadalafil (Cialis)
Vardenafil (Levitra)
Also used for pulmonary HTN
(Revatio), Altitude sickness, mixed
with illicit drugs (beware amyl nitrate),
cut flowers.

12. Eligible on NHS Diabetes MS Parkinsons Poliomyelitis Prostate Ca
Prostatectomy incl TURP
Radical pelvic surgery
Renal failure treated by
dialysis or transplant
Severe pelvic injury
Single gene neurological disease
Spinal cord injury
Spina bifida
Receiving Tx 14/09/98
Impotence causing severe distress (after hospital assessment)
One a week is appropriate, prescribers discretion to choose to give more

13. Contraindications Organic nitrates
Hypotension <90/50. Careful use with alpha blockers
Severe hepatic impairment
Hereditary degenerative retinal disorders eg retinitis pigmentosa
Recent stroke or MI
Careful use with other
P450 inhibitors eg
cimetidine

14. Sublingual Apomorphine
Dopamine agonist
Not as effective as Sildenafil
Only licensed oral drug not absolutely contraindicated for use with nitrates
Positive response in 40-50% patients

15. Intracavernosal Injections
Alprostadil, Prostaglandin E1 causes vasodilation
Effective in up to 80%
Few contraindications or interactions
Requires training, manual dexterity,
eyesight
Pain on injection
Also used to maintain patent
ductus arteriosus

16. Transurethral Alprostadil
Effective in 10mins, lasts 20-60mins
Less effective than intracavernosal and slower acting, but less incidence of priapism

17. Vacuum Devices
Plastic cylinder, vacuum created by hand or electric pump
Constriction ring around base of penis
Reported long term success in up to
60% of patients

18. Penile Prostheses Two types Malleable pair of rods with metal core
Inflatable cylinders with internal
pump and reservoir
For patients that have failed to
respond to other treatments or have
developed fibrosis
Risk of infection, erosion through the
glans

19. Clinical Evidence Review
Evidence of benefit:
Alprostadil (both intracavernosal and transurethral), Apomorphine, Sildenafil, Tadalafil, Vardenafil
Likely to be beneficial:
Ginseng, prosthesis, psychosexual counselling, vacuum devices, yohimbe bark

20. Referral From Primary Care
Urology
Young men that have always had difficulty
Hx of trauma (genitals, pelvis, spine)
Clinical abnormality (micropenis, peyronies)
Fail to respond to at least 2 max dose PDE5 Inhibitors
Endocrinology
Hypogonadism, abnormal testosterone,
prolactin
Cardiology
Disease making sex or PDE5 use unsafe
Psychologists

21. Summary Common – 52% aged 40-70 Multiple causes
Take comprehensive history
Investigate cardiovascular disease
Consider psychological management
Multiple treatments – First line Sildenafil
Check if qualifies for NHS treatment and contraindications
Refer as approprtiate