Erectile Dysfunction (ED) Shawn McGee M.D. CentraCare Adult and Pediatric Urology January 30 th, 2016

Transcription

1 Erectile Dysfunction (ED) Shawn McGee M.D. CentraCare Adult and Pediatric Urology January 30 th, 2016

2 Erectile dysfunction: The inability to attain or maintain penile erection sufficient for satisfactory sexual performance 52% of men >40 have some degree of ED Testosterone decreases as age increases Treated HTN has a higher rate of erectile dysfunction than untreated HTN

3 How Common Is It? 1 in 10 men 1 Over 30 million American men 2 90% physical, 10% psychological 3 1"Facts About Erectile Dysfunction." Minnesota Men's Health Center, P.A Minnesota Men's Health Center, P.A.. 23 Jan 2009 < 2 Sun P, Seftel A, Swindle R, Ye W, Pohl G. The costs of caring for erectile dysfunction in a managed care setting: evidence from a large national claims database. J Urol Nov;174(5): Mulligan T, Teitelman, J. Geriatric sexual dysfunction. Va Med Q Spring;118(2):97-9.

4 Objectives Understand physiology Work-up CV risks assessment of men resuming sexual activity Basic diagnostics Treatment

5 Physiology Erections require 2 main processes Cavernosal artery smooth muscle relaxtion Active process initiated by parasympathetics (NitOx) Increased venous outflow resistance (passive) Detumescence Smooth muscle contraction Sympathetics (NorEpi)

6 Parasympathetic Nerve Adenylate Cyclase ATP Cavernosal a. Smooth Muscle NitOx Guanylate Cyclase GTP PDE2,3,4 camp 5-AMP Relaxation of smooth muscle Contraction of smooth muscle cgmp 5-GMP PDE5 Alpha-1 Receptor NorEpi Sympathetic Nerve

7 Physiology Adenylate cyclase *Alprostadil stimulates this receptor Phosphodiesterase PDE 2, 3, 4, 5 *Papaverine inhibits all these enzymes PDE 5 Sildenafil, tadalafil, vardenafil inhibit this enzyme Alpha-1 receptor *Phentolamine inhibits this receptor * Constituents of TRIPLE MIX injections

8 Work-up History Nocturnal erections, erection with masterbation vs. partner (aka anxiety), libido, curvature Medications: B-blockers, clonidine, thiazides, antidepressants, sedatives (Not ACE inhibs) CRF, DM, ETOH, thyroid dysfunction, CAD Prostate surgery, vascular surgery, colorectal surgery, SCI, pelvic fracture, radiation

9 Work-up Physical Exam Pulses External genitalia DRE Testicular size, penile plaques Sphincter tone, perianal sensation Gynecomastia Visual field defecits

10 Cardiovascular Risk Assessment of Men Resuming Sexual Activity ED may serve as early indicator of CAD BP measurements, Hbg A1c, Sexual activity increases the risk of MI by 2-3 fold Sex causes < 1% of MIs Absolute risk of MI 2 hours after sex <0.01%

11 Cardiovascular Risk Assessment of Men Resuming Sexual Activity CV meds Nitrates: Contraindicated with use of PDE-5 inhibs Anti-arrhythmics: Vardenafil (Levitra) contraindicated b/c of QT prolongation Alpha-blockers: Use caution with PDE5 inhibs Anticoagulants: VED contraindicated, caution for intracavernosal injections

12 Cardiovascular Risk Assessment of Men Resuming Sexual Activity ED meds Patients with known CAD or CHF on PDE5 inhibs DID NOT demonstrate worse hemodynamics or ischemia during stress tests. Aortic stenosis can be sensitive to vasodilation Testosterone contraindicated in patients with untreated CHF, volume overload, pulmonary edema

13 Cardiovascular Risk Assessment of Men Resuming Sexual Activity *High risk for treatment Unstable angina Uncontrolled HTN LVD/CHF NYHA (III/IV) MI within 2 weeks High risk arrhymias Obstructive hypertrophic cardiomyopathy Moderate or severe valvular disease Refer to Cardiologist *Based on recommendations from Princeton Consensus Conference

14 Cardiovascular Risk Assessment of Men Resuming Sexual Activity *Low risk for treatment Asymptomatic CAD < 3 CAD risk factors (exclude being a man) Controlled HTN with > or 1 medications Uncomplicated MI > 2 months ago Mild stable angina Successful coronary revascularization Mild valvular disease Treat ED, resume sexual activity *Based on recommendations from Princeton Consensus Conference

15 Basic Diagnostics Testosterone (hypogonadism) Total testosterone (nl? >250 to 1000?) Morning testosterone If testosterone low then LH and prolactin Prolactin (pituitary tumor) Visual field defects Headaches Gynecomastia Decreased libido Hbg A1c, Lipid profile, CBC (anemia), Chem-8 (CRF), thyroid panel Self administered questionnaires (SHIM score)

16 Further Diagnostics Combined intracavernosal injection and stimulation Penile duplex Doppler sonography Arterial flow (PSV, CD, EDV) Cavernosometry Cavernosography Internal pudendal arteriography

17 Treatment Options Oral Medications (Viagra, Levitra, Cialis ) Vacuum Erection Devices Injection Therapy Urethral Suppositories Penile Implants Viagra is a trademark of Phizer, Inc., Levitra is a trademark of Bayer and GlaxoSmithKline and Cialis is a trademark of Lily ICOS

18 Treatment PDE-5 inhibitors Physical stimulation required Do not initiate erection but make it more rigid Need libido AUA recommends as first line treatments Viagra (sildenafil) Levitra (vardenafil) Cialis (tadalafil)

19 PDE-5 Inhibitors Viagra & Levitra versus Cialis (V) & (L) GI absorption reduced by fatty foods (V) & (L) half life 4 hrs versus (C) 18 hrs (V) & (L) duration of action 6 hrs versus (C) 36 hrs (V) & (L) affinity for PDE-6 = visual side effects (C) affinity for PDE-11 = back pain and myalgias

20 Treatment Options: Efficacy Oral Medications (Viagra, Levitra, Cialis ) ALL PDE-5 inhibitors equivalent and well tolerated ~70% effective in general population 1 Less effective in diabetics and prostatectomy patients Vacuum Erection Devices 68-83% satisfaction rate 1 Injection Therapy Trimix (89% adequate erections) 1 Urethral Suppositories MUSE (66% respond) 1 Penile Implants 1 Cambell-Walsh Urology. 9th Ed. Reproductive and Sexual Function

21 Some Are More Satisfying Than Others Oral Medications: not effective in 30% of cases 1 Vacuum Erection Devices: cumbersome, unromantic Injection Therapy: needles, expensive, may cause burning sensation, long term scarring Urethral Suppositories: expensive, may cause burning sensation 1 Goldstein I, Lue TF, Padma-Nathan H, Rosen RC, Steers WD, Wicker PA; Sildenafil Study Group. Oral sildenafil in the treatment of erectile dysfunction J Urol Feb;167(2 Pt 2): ; discussion 1204

22 Types of Penile Implants One-piece non-inflatable Two-piece inflatable Three-piece inflatable

23 Penile Implant Versus Other Treatment Options Overall Patient Satisfaction with ED Treatments 1 Penile Implant 0% 20% 40% 60% 80% 100% 93% Oral Medication 51% Penile Injection 40% Percentage Satisfied 1 Rajpurkar A, Dhabuwala CB. Comparison of satisfaction rates and erectile function in patients treated with sildenafil, intracavernous prostaglandin E1 and penile implant surgery for erectile dysfunction in urology practice. J Urol Jul 2003 v.170(1)p

24 Penile Implants Ideal for men who have tried other treatments without success On the market for over 30 years 25,000 penile implants per year 1 Over 300,000 implants to date 2 High patient and partner satisfaction 3 1 Millenium Research Group. US Markets for Urological Devices May "Penile Prosthesis." The Sexual Medicine Web Site European Society for Sexual Medicine. 23 Jan 2009 < area/penileprosthesis.asp>. 3 Levine LA, Estrada CR, Morgentaler A. Mechanical reliability and safety of, and patient satisfaction with the Ambicor inflatable penile prosthesis: results of a 2 center study. J Urol Sep;166(3):932-7

25 Three Piece Inflatable Penile Implant Advantages Same advantages as the two - piece plus: Acts and feels more like a natural erection Expands the girth of the penis More firm and full than other implants Feels softer and more flaccid when deflated Disadvantages Requires some manual dexterity Possibility of leakage or malfunction Possibility of unintentional erections

26 Implants are Highly Recommended 100% 95% 90% 85% 80% 92% would recomm end to others 90% partners would recommend to other Couples Levine LA, Estrada CR, Morgentaler A. Mechanical reliability and safety of, and patient satisfaction with the Ambicor inflatable penile prosthesis; results of a 2 center study. J Urol Sep; 166 (3) :932-7