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Erectile dysfunction ( ED ) Persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance
Very common disorder Massachusetts Male Aging Study ( MMAS ) 1987-97 an important study revealed that 52 % men ( aged 40-70 yrs ) reported erectile dysfunction Prevalence and severity ↑es with age ED is a strong predictor of CVD in particular CAD
Risk factors Shares both unmodifiable and modifiable risk factors with CVD ○ diabetes ○ obesity ○ dyslipidemia ○ metabolic syndrome ○ lack of exercise ○ smoking , alcohol Age Poor physical and psychological health Lower urinary tract symptoms and BPH
Causes – vasculogenic Generalised CV disease Hypertension Hyperlipidemia Diabetes Smoking Major pelvic surgery or Radiotherapy ( pelvis or retroperitoneum ) Neurogenic -Degenerative disorders -eg multiple sclerosis , Parkinson’s , multiple atrophy etc Spinal cord trauma or diseases Stroke CNS tumours Hormonal-Hypogonadism Hyperprolactinaemia Hyperthyroidism , Hypothyroidism Cushing’s disease Hypopituitarism following traumatic brain injury Anatomical-Eg cavernous fibrosis , Peyronie’s disease and penile fracture , micropenis , hypospadias , epispadias Psychological-Can be predisposing ( risk factors ) precipitating ( present ) or maintaining ( ongoing ) causes
History –Detailed medical and sexual history Comorbid conditions eg hypertension , peripheral vascular disease , diabetes , obesity , renal disease Sexual history should include ○ sexual orientation ○ previous and current sexual relationships ○ current emotional status ○ onset and duration of erectile problem ○ previous consultations and treatments Validated psychometric questionnaires such as ○ International Index for Erectile Function ( IIEF ) or ○ Sexual health Inventory for Men ( SHIM ) – shorter version of IIEF can be used Two question scale for depression ( if depression suspected) ○ during the past month have you often been bothered by feeling down , depressed or hopeless ? ○ during the past month have you often been bothered by little interest or pleasure in doing things ? Lifestyle including alcohol , tobacco , illicit drugs Symptoms of hypogonadism – loss of libido , loss of body hair , spontaneous hot flushes Pelvic surgery , radiation , trauma Medications
Examination-Focused physical examination ○ body weight ○ waist circumference ○ heart rate ○ blood pressure ○ pulses and sensation Examine genitalia ○ may reveal hypogonadism ( small testes ) ○ Peyronie’s disease Check for gynaecomastia and reduced body hair DRE- if symptoms of enlarged prostate ○ obstructive urinary symptoms in ED erection loss happens before orgasm whereas in premature ejaculation it happens afterwards
Calculate the 10 year CV risk ( eg using QRisk2 calculator ) ○ If not tested recently consider fasting blood glucose or Hba1c and lipid profile ○ ECG can be considered in younger men (< 60 ) Controversy exists on the ideal endocrine workup Free testosterone in the morning ( between 9-11 AM ) Repeat testosterone SHBG Check FSH LH Prolactin levels
Lifestyle –Usually responds well to combination of lifestyle changes and drugs Lifestyle advice ( where applicable ) ○ weight loss ○ smoking cessation ○ ↓ alcohol intake ○ ↑ exercise
All PDE5-Inhibitors slow the degradation of cGMP Inhibition leads to prolonged activity of cGMP Decreases the intracellular Calcium conc , maintains smooth muscle relaxation Rigid penile erections Men with Coronary Heart Disease- Most men can safely resume sexual activity and use PDE-5Is. Exception being Unstable heart disease H/O recent MI ( CKS NHS – within 6 months ) Poorly compensated heart failure Unstable dysarrythmia
Contraindications- If on nitrates in any form ( risk of severe hypotension ) Who have lost sight in one eye due to non-arteritic anterior ischaemic optic neuropathy Hypotension ( systolic < 90 ) Recent stroke Unstable angina Vardenefil is CI in ○ severe hepatic impairment ○ end stage renal disease patients on dialysis ○ known hereditary retinal degenerative disorders as retinitis pigmentosa Sildenefil is CI in ○ severe hepatic impairment ○ hereditary degenerative disorders as PRetinosa Tadalafil is CI in men with ○ NYHA class2 or greater heart failure in the last 6 months ○ uncontrolled arryhtmias ○ uncontrolled hypertension Caution-CV disease LV outflow obstruction Anatomical deformation of penis ( eg angulation , cavernosal fibrosis or Peyronie’s disease ) Predisposition to priapism eg ○ sickle cell disease ○ Multiple-myeloma ○ Leukaemia
35 % patients may fail to repond- common causes Diabetes , severe neurological or vascular diseases Start low and titrate upwards if ineffective
LINKS AND RESOURCES
PATIENT INFORMATION
Information from British Association of Urological Surgeons ( printable 7 pages ) https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Erectile%20dysfunction.pdf
Urology Care Foundation – ED patient Guide- a complete patient guide- autodownload 12 pages https://www.urologyhealth.org/Documents/Product%20Store/Erectile-Dysfunction-Brochure.pdf
Printable 6 pages leaflet from Sexual Advice Association https://sexualadviceassociation.co.uk/wp-content/uploads/2016/02/Men-9.-Erectile-dysfunction-V4.pdf
Weblink for the page https://sexualadviceassociation.co.uk/erectile-dysfunction/
3 page information leaflet from Andrology Australia -very informative https://www.healthymale.org.au/files/resources/erectile_dysfunction_fact_sheet_healthy_male_2019.pdf
International Index of Erectile Dysfunction – patient questionnaire https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/iief.pdf#
The Sexual Health Inventory for Men ( SHIM ) Questionnaire https://www.pcf.org/c/the-sexual-health-inventory-for-men-shim-questionnaire/
INFORMATION FOR CLINICIANS
A very useful article from Australian Family Physician – Much more than prescribing a pill – Assessment and treatment of ED by the GP https://www.racgp.org.au/afp/2017/september/much-more-than-prescribing-a-pill/
Tips on talking about this problem – from AMS Health https://www.amsmenshealth.com/content/dam/American-Medical-Systems/diabeticEducators/tips/MH-397502-AA_Tips%20for%20the%20ED%20Talk-ED_FINAL.pdf
European Association of Urology Guidelines on ED , Premature Ejaculation , Penile Curvature and Priapism 2016 https://uroweb.org/wp-content/uploads/EAU-Guidelines-Male-Sexual-Dysfunction-2016-3.pdf
American Urological Association Guideline on ED 2018 https://www.auanet.org/guidelines/erectile-dysfunction-(ed)-guideline
Canadian Urological Association CUA Practice guidelines on ED 2015 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4336024/
British Society of Sexual Medicine Guidelines on the Management of ED 2017 http://www.bssm.org.uk/wp-content/uploads/2018/09/BSSM-ED-guidelines-2018-1.pdf
A comparison of guidelines between the UK and Europe from Journal of Clinical Urology –https://www.baus.org.uk/_userfiles/pages/files/professionals/sections/ED.pdf
BNF on PDE5 inhibitors https://bnf.nice.org.uk/treatment-summary/erectile-dysfunction.html
Type 2 diabetes management on A4Medicine ADA -EASD guideline https://a4medicine.co.uk/ada-easd-guideline-management-type-2-diabetes/
References
- Clinical Review – Erectile dysfunction BMJ 2014 ; 348; g129
- Shamloul R, Ghanem H. Erectile dysfunction. Lancet. 2013;381(9861):153‐165. doi:10.1016/S0140-6736(12)60520-0 https://pubmed.ncbi.nlm.nih.gov/23040455/
- Bella, Anthony J et al. “2015 CUA Practice guidelines for erectile dysfunction.” Canadian Urological Association journal = Journal de l’Association des urologues du Canada vol. 9,1-2 (2015): 23-9. doi:10.5489/cuaj.2699 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4336024/
- CKS NHS Erectile dysfunction Dec 2014 https://cks.nice.org.uk/erectile-dysfunction
- Guidelines on Male Sexual Dysfunction: Erectile dysfunction and premature ejaculation
K. Hatzimouratidis (Chair), I. Eardley, F. Giuliano, I. Moncada, A. Salonia https://uroweb.org/wp-content/uploads/EAU-Guidelines-Male-Sexual-Dysfunction-2015-v2.pdf - Pharmacological treatment of erectile dysfunction BMJ 20014 ; 329 : E310
- Guideline for the investigation and management of erectile dysfunction . Alberta Medical Association – via https://actt.albertadoctors.org/CPGs/Lists/CPGDocumentList/ED-Summary.pdf
- Erectile Dysfunction Am Fam Physician . 2016 Nov 15;94 (10 ): 820-827 (Abstract )
- Guidance for prescribing phosphodiesterase type-5 ( PDE5) inhibitors for erectile dysfunction in primary care North West Commissioning Support unit 2015
- Ludwig W, Phillips M. Organic causes of erectile dysfunction in men under 40. Urol Int. 2014;92(1):1-6. doi: 10.1159/000354931. Epub 2013 Nov 21. PMID: 24281298. ( Abstract )
- Kubin M, Wagner G, Fugl-Meyer AR. Epidemiology of erectile dysfunction. Int J Impot Res. 2003 Feb;15(1):63-71. doi: 10.1038/sj.ijir.3900949. PMID: 12605242. ( Abstract )
- Patel, D V et al. “Investigation of erectile dysfunction.” The British journal of radiology vol. 85 Spec No 1,Spec Iss 1 (2012): S69-78. doi:10.1259/bjr/20361140
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Recent advances in the treatment of erectile dysfunction